List of Tables

Table 1. Demographic Questions...................................................................................... 79

Table 2. Semistructured Interview Questions & Prompts ................................................ 80

Table 3. Participant Demographics ................................................................................... 89

Table 5. Initial Cycle of Coding Examples....................................................................... 90

Table 5. Second Cycle Coding Examples ......................................................................... 92

Table 6. Final Themes....................................................................................................... 96

v
 List of Figures

Figure 1. Ecological Systems Theory Model.................................................................... 23

Figure 2. Brain Diagram ................................................................................................... 42

Figure 3. Healthy and Abused Brain................................................................................. 43

Figure 4. Word Cloud Generator Results ......................................................................... 95

vi
 1
Chapter 1: Introduction to the Study

Trauma has been linked with an increased likelihood to suffer from physical

health problems, mental health issues, substance abuse issues, and financial problems

including a cost to the United States economy of $671 billion dollars a year (Coalition for

National Trauma Research [CNTR], 2020). Some human service organizations have

moved to incorporate trauma-informed practices due to the increased potential for

traumatized individuals to be retraumatized by existing standard practices and policies

(Loomis, 2018), but these may not be consistent across organizations and services

(Carello & Butler, 2015; Champine et al., 2019; Hanson & Lang, 2016). The problem

that was addressed in this study were the negative repercussions of retraumatization due

to those organizations and systems not being based in trauma-informed approaches

(Ezell, 2019; Huefner et al., 2020; Medenhall et al., 2018; Mersky et al., 2019; Salloum et

al., 2018).

The purpose of this generic qualitative research study was to d escribe and

understand case managers’ perceptions of trauma-informed practices and policies across

organizations and services. I sought to understand the level of training and education case

managers had before providing services to victims of trauma. I also sought to understand

the policies and practices implemented in human services organizations. Thus, the focus

was on case managers’ perceptions of trauma-informed policies and practices that are

used in their organizations. Case managers in human service organizations interact with

different levels of ecological systems that influence the perceptions, attitudes, and

behaviors that then affect how case managers interact with clients (Cornell University,
 2
2019). The inclusions of trauma-informed policies and practices of a system, or lack of

trauma-informed policies and practices, guide how clients are interacted with and may

results in positive or negative outcomes for that client (Dember et al., 1999; Purtle, 2018).

How case managers are influenced to use, or not use, trauma-informed policies and

practices when having interactions with victims of trauma can influence how individuals

receive services, directly affecting their health and well-being.

Describing how case managers perceive trauma-informed practices and policies

within the organizations they work may help to provide vital information on how to

prepare case managers to work with victims of trauma and minimize retraumatization.

The data may also help to inform training of case managers on how to best work with

clients who have experienced trauma. In addition, it may also provide information about

human service case managers’ level of preparedness in working with trauma victims and

what other measures they feel can be taken to help them be better trauma-informed. Data

on their perceptions of the trauma-informed practices and policies within human services

organizations may also help organizations better provide a trauma-informed work culture

for their employees and clients. In this chapter, I discuss background information related

to the study, the research problem, the purpose of the study, and the research question. I

also discuss the theoretical framework, the nature of the study, definition of key terms,

scope and limitations, delimitations as well as the significance of the study.

Background

Trauma is a distressing or life-threatening event that causes immense fear, horror,

or helplessness (American Psychological Association [APA], 2022; Kiser et al., 2008). It

 3
happens when an individual is exposed to an external threat and is unable to cope with

having experienced that threat (Bloom, 1999). Trauma changes the way one thinks, feels,

remembers, learns, and makes sense of the world because it interferes with brain

functioning (Bloom, 1999; Van der Kolk & Saporta, 1991). When symptoms of stress

persists at least several weeks or longer and interferes with the individual’s personal,

family, social, occupational, or educational functioning, it can develop into trauma and

possibly post-traumatic stress disorder (PTSD) (Australian Health and Welfare, 2020).

The National Council on Behavioral Health ([NCBH], n.d.) found that 70% of the

U.S. population have experienced at least one trauma in their lifetime. In addition, 90%

of clients in public behavioral health programs have experienced trauma and 60% of men

and 50% of women will experience at least one trauma in their lifetime (NCBH, n.d.;

U.S. Department of Veteran Affairs, n.d.). Experiencing trauma costs society in the

United States $458 billion per year (Berger, 2019; CDC, 2023). Researchers have also

found a direct link between trauma and diabetes, high blood pressure, heart disease,

cancer, and chronic obstructive pulmonary disease (NCBH, n.d.).

The most common traumas experienced by women and youth in the United States

are sexual assault and child sexual abuse (APA, 2022; U.S. Department of Veteran

Affairs, n.d.). Men and boys are more likely to experience trauma related to accidents,

physical assaults, combat, disaster, or witnessing death or injury (APA, 2022; U.S.

Department of Veteran Affairs, n.d.). Racial and ethnic minority groups and families and

immigrant youth and families are more likely to experience trauma due to poverty and

discrimination (APA, 2022).

 4
Three types of trauma that individuals may experience include acute, chronic, and

complex trauma (McGonagle & Kessler, 1990; Missouri Early Care & Education

Connections, n.d.; National Child & Traumatic Stress Network, n.d.; Pain, 2019; Ross et

al., 2021). Acute trauma is trauma from a singular life event such as a death, job loss, or

separation/divorce, or natural disaster (McGonagle & Kessler, 1990; Ross et al., 2021).

Chronic trauma is prolonged exposure to traumatic events such as having a parent that

gets violent when they drink which an individual is growing up and experiencing

homelessness over and over (McGonagle & Kessler, 1990; Missouri Early Care &

Education Connections, n.d.; National Child & Traumatic Stress Network, 2016).

Complex trauma is exposure to multiple traumatic events sequentially or at the same time

such as losing one’s home and then being assaulted when living at a shelter (Missouri’s

Early Care & Education Connections, n. d.; Ross et al., 2021).

Trauma can happen at any point in an individual’s life, but adverse childhood

experiences (ACEs) can continue to affect individuals as adults (Van der Kolk, 1991).

Some children may experience dissociations (defense mechanisms), which are protective

factors for trauma. Dissociation involves disengagement, withdrawal, and daydreaming

which are characterized as negative repercussions of trauma (Hunter-Dehn, 2021). These

negative repercussions also include intrusive thoughts/recollections, hypervigilance,

exaggerated startle, dissociation, mood disturbances, psychological reactivity to

reminders, physiological reactivity to reminders, and distorted cognitions amongst many

other symptoms (Hunter-Dehn, 2021).

Retraumatization happens when victims experience trauma symptoms from a

 5
previous traumatic event triggered by a new situation or event (Alexander, 2012; Butler

et al., 2018). It is related to poor treatment outcomes and more severe symptoms found to

be related to trauma (Lawson et al., 2020). The timing of subsequent traumas and the type

of traumatic event has an impact on whether the individual feels retraumatized.

Retraumatization has also been found to be higher in individuals of color (Butler et al.,

2018).

Systems, such having to answer questions about the traumatic event repeatedly to

get services or support, that recreate this feeling or environment retraumatize victims

(Newgent et al., 2003). Victims can also feel traumatized due to the response they may

receive from victim serving agencies (Becker-Blease, 2017; Substance Abuse and Mental

Health Services Administration [SAMHSA], 2014). One way that systems retraumatize is

by not providing the necessary resources to support victims of trauma (Becker-Blease,

2017; Zgoda et al., 2016). The lack of knowledge, awareness, and training are elements

in the healthcare system that may perpetuate retraumatization (Schippert et al., 2021). It

is important for these agencies to learn how to support those victims in a trauma-

informed manner (Newgent et al., 2003).

The field of human services covers a large umbrella of services ranging from

healthcare and counseling services to food and shelter (Human Services Edu, 2022;

Martin & Haslett-Knudsen, 2012). Human services case managers deliver services to

meet the needs and improve the quality of life of those that they work with (American

Case Management Association, 2020; Commission for Case Manager Certification,

2022). Case managers also make sure that provided services are safe, effective, client-
 6
centered, and efficient (Case Management Society of America, 2021; Commission for

Case Manager Certification, 2022). The prevalence of trauma, adverse effects, and the

cost of trauma has encouraged human service organizations to address trauma by creating

trauma-informed programs (Classen & Clark, 2017; Lang et al., 2016). Trauma-informed

practice considers the effects of trauma and the role that it plays in shaping human

growth and development (Ezell et al., 2018). It is the utilization of relational,

organizational, and trauma theory related to the strategies and interventions used in

treatment and service delivery (Bent-Goodley, 2019; Shier & Turpin, 2017). The purpose

of trauma-informed practice and policy is to consider the multiple facets of trauma and

how they relate to the individual so that one does not retraumatize the individual

(Maynard et al., 2019; SAMHSA, 2014). Case managers in human service organizations

interact with different levels of ecological systems that influence the perceptions,

attitudes, and behaviors that then affect how case managers interact with clients (Cornell

University, 2019). The inclusions of trauma-informed policies and practices (TIPP) of a

system, or lack of trauma-informed policies and practices, are important elements that

guide how clients are interacted with and may results in positive or negative outcomes for

that client (Dember et al., 1999). How case managers are influenced to use (or not use)

trauma-informed policies and practices when having interactions with victims of trauma

can have an influence on how individuals receive services, directly affecting the health

and well-being of individuals. I found few researchers who studied case managers’

perceptions of trauma-informed practice and policies in human services organizations

where they provide case management services for trauma victims (Donahue, 2020; Ezell,
 7
2019). Further research was warranted that could explore case managers’ perceptions of

trauma-informed care (TIC), trauma-informed practice (TIP), and trauma-informed

policies within their organizations to address the problem of the negative repercussions of

retraumatization experienced at the hands of organizations and systems that are meant to

help victims of traumatic events.

Problem Statement

Sixty percent of adults have reportedly experienced abuse or family issues during

childhood, and 60% of youth ages 17 and under have experienced or witnessed crime,

violence, or abuse (North Dakota Department of Human Services, n.d.). Trauma has been

linked with an increased likelihood to suffer from serious health problems, mental health

issues, substance abuse issues, and serious financial problems costing the U.S. economy

$671 billion dollars a year (CNTR, 2020). Further, organizational practices and treatment

settings have been found to be a source of retraumatization for trauma victims (Bloom,

2017; Grossman et al., 2021). Retraumatization is the reexperiencing of trauma

symptoms from a previous traumatic event triggered by a new situation or event

(Alexander, 2012; Weiss, 2021). The experiences victims have had in courtrooms, child

welfare systems, juvenile justice systems, and mental health treatment facilities have

been found to elicit painful physical and emotional reminders of the trauma previously

experienced that have caused them to interact with that system (Crenshaw et al., 2019;

Katirai, 2020; Lamminen et al., 2020; Smith & Bowman, 2009). As a result of this

retraumatization, victims of previous traumatic events experience nightmares, intrusive

 8
thoughts or memories, anger, shame, withdrawal, isolation, and/or feelings of being

unsafe in addition to various other symptoms (Loughran & Reid, 2018; SAMHSA, 2014).

TIC and TIP models emerged that aimed to change systems of care through

psychoeducation on the delivery of services, psychological safety, and victim autonomy

(Bryson et. al, 2017). Some public systems are incorporating TIP due to the increased

potential for traumatized individuals to be retraumatized by standard practices and

policies (Loomis, 2018), but these may not be consistent across organizations and

services (Carello & Butler, 2015; Champine et al., 2019; Hanson & Lang, 2016).

Therefore, the problem that was addressed in this study were the negative repercussions

of retraumatization such as feelings of being unsafe, anger, guilt, shame, depression, and

secondary trauma at the hands of organizations and systems that are meant to help

victims of traumatic events due to those organizations and systems not being based in

trauma-informed approaches. (Ezell, 2019; Huefner et al., 2020; Medenhall et al., 2018;

Mersky et al., 2019; Salloum et al., 2018).

There is research regarding the negative outcomes to victims of trauma associated

with retraumatization (Bloom, 2017;CNTR, 2020; Katirai, 2020; North Dakota

Department of Human Services, n.d.; SAMHSA, 2014), the importance of TIC (Bryson

et al., 2017; Hanson & Lang, 2016), TIP (Crenshaw et al., 2019; Ezell et al., 2018; Smith

& Bowman, 2016), and trauma-informed policies (Herrenkohl et al. 2019; Rodriguez,

2016; Tuck et al., 2017). However, I found few researchers who studied case managers’

perceptions of TIPP in human services organizations where they provide case

management services for trauma victims (Donahue, 2020; Ezell, 2019). Further research
 9
was warranted that could explore case managers’ perceptions of TIC and TIPP within

their organizations to address the problem of the negative repercussions of

retraumatization experienced at the hands of organizations and systems that are meant to

help victims of traumatic events.

Purpose of the Study

The purpose of this generic qualitative research study was to d escribe and

understand case managers’ perceptions of TIPP across organizations and services. I

sought to understand the level of training and education case managers had before

providing services to victims of trauma. I also sought to understand the policies and

practices implemented in human services organizations. I wanted to know whether case

managers felt the current policies and practices were beneficial to themselves and victims

of trauma. Researchers highlighted numerous implementation efforts of TIPP, but

describing case managers’ beliefs and attitudes about the practices and policies of their

organization helped to inform human service agencies on best practices, policy, and

training needs (Bryson et al., 2017; Ezell et al., 2018).

Research Question

What are case managers’ perceptions of trauma-informed practice and policy in

human service organizations?

Theoretical Foundation for the Study

Ecological systems theory (EST) was utilized as the theoretical framework for

this study. EST is used to describe how social, environmental, political, and cultural

systems help to shape human development (Guy-Evans, 2020). According to EST, the
 10
individual is affected by five interrelated systems: microsystem, mesosystem, exosystem,

macrosystem, and chronosystem (Guy-Evans, 2020). Bronfenbrenner (1979) pointed out

how an individual perceives their environment is important to their behavior and

development and that this environment includes a variety of environments at different

levels and interactions within and between these levels.

Trauma and retraumatization can be experienced within, or across, any of these

systems (DeCandia & Guarino, 2015; Zhu et al., 2020). The microsystem is a direct

environmental setting surrounding the developing individual. It includes the relationships

directly affecting the developing individual such as those in the home (Bronfenbrenner,

1979; Martinello, 2019). The setting encompasses place, time, physical features of the

setting, activity, participant, and role (Bronfenbrenner, 1977). One example of trauma at

the microsystem level is intimate partner violence (IPV). Negative events within the

immediate family would disrupt the microsystem level affecting the relationships in the

mesosystem.

The mesosystem is a variety of microsystems interacting with one another

(Bronfenbrenner, 1979; Hӓrkӧnen, 2007; Martinello, 2019). The interaction between the

various settings happens when individuals move into a new setting (Bronfenbrenner,

1977). These settings can include the workplace, peer groups, religious groups, social

groups, or associations in the neighborhood (Bronfenbrenner, 1977, 1979). IPV victims

may have negative experiences seeking services to assist them (Guy-Evans, 2020; Zhu et

al., 2020). For example, court proceedings often become very adversarial because the

victims often face questioning that feels accusatory (Katirai, 2020). This process causes
 11
retraumatization and victims may choose to forgo court proceedings (Katirai, 2020).

The exosystem are the social structures that indirectly influences the individual’s

life (Martinello, 2019). Media becomes a part of the exosystem, where the individual is

not a direct participant, in that it infiltrates the home via various external methods

(Bronfenbrenner, 1979). Media can influence how individuals perceive intimate partner

violence because the public has largely relied on the media to understand IPV as a social

issue (Carlyle et al., 2014). Men are characterized as naturally aggressive and women

who perpetuate IPV are justified for their behavior (Carlyle et al., 2014; Walker et al.,

2020).

The macrosystem are institutions or social structures within the society that the

individual lives are representative of a larger society and its belief systems

(Bronfenbrenner, 1979). Immigrant women who experienced IPV have been found to

make decisions about how to deal with the IPV based upon the accurate or

misinformation of immigration rules and policies (Alaggia et al., 2012; Murshid &

Bowen, 2018). Immigration policies may not be designed with the thought of mitigating

factors that lead some individuals to have contact with immigration services (Alaggia et

al., 2012; Murshid & Bowen, 2018).

The chronosystem, which was added during the second phase of the development

of Bronfenbrenner’s model (and the version of EST that I am using), refers to the

environmental changes that occur over the individual’s life (Guy-Evans, 2020). The

chronosystem is focused on time and how relationships can change over time as well as

the interaction between systems over time (Eriksson et al., 2018; Martinello, 2020).
 12
Trauma can happen as a single event in time, multiple events on separate occasions,

multiple events in one moment, or a single event/multiple events happening over a longer

span of time (prolonged exposure to trauma; APA, 2021; Kiser et al., 2008). Time is also

relevant to how an individual sees the future as well. It is likely for individuals to feel

hopeless and pessimistic about the future because they are unable to think beyond where

they are in the moment causing changes to their emotional states or thinking (Pill et al.,

2017; Warmingham et al., 2021).

The interactions between each system of the EST are important because they

highlight the ecological orientation from a phenomenological perspective

(Bronfenbrenner, 1979). The most powerful influence on the individual happens at the

microsystem level (Crawford, 2020; Hӓrkӧnen, 2007). The family helps to shape growth

and development by influencing each other’s beliefs and behavior (Darling, 2007). The

relationship between the individual and its community (e.g., neighborhood, church, and

school) has a residual impact on the individual’s relationships with their family. Given

such, the communication and interaction form a dual relationship which constitutes as a

mesosystem. However, the individual does not have to be present or actively participate

in a setting for it to exert some type of influence over the individual (Bronfenbrenner,

1977; 1979). Therefore, the experience would take place within the exosystem.

Public policies and laws are designed to influence change at the micro-, meso-,

and exosystem levels and activism can influence the policies created at the macrosystem

level which should trickle down to all the levels below the macrosystem. However,

inconsistencies and conflicting policies can result in retraumatization. For instance,

 13
immigration policies may not be designed with the thought of mitigating factors that lead

some individuals to have contact with immigration services (Alaggia et al., 2012;

Murshid & Bowen, 2018). Time also plays a role in the effects of trauma over time,

traumatic experiences being repeated, and how one heals (Carlson & Dalenberg, 2000;

Hӓrkӧnen, 2007).

Case managers in human service organizations interact with different levels of

ecological systems that influence the perceptions, attitudes, and behaviors that then affect

how case managers interact with clients (Cornell University, 2019). The inclusion of

TIPP of a system, or lack of TIPP, are important elements that guide how clients are

interacted with and may result in positive or negative outcomes for that client (Dember et

al., 1999; Purtle, 2018). How case managers are influenced to use, or not use, TIPP when

having interactions with victims of trauma can influence on how individuals receive

services, directly affecting the health and well-being of individuals. Human service

professionals who provide services to clients who have been traumatized are influenced

by individual factors (family, personal experiences, education, etc.) as well as other levels

encountered that the EST explains (Bronfenbrenner, 1979). The client is also interacting

with many different levels explained by EST and some of these interactions/levels may or

may not cause retraumatization (Guy-Evans, 2020). Therefore, the theory of EST does

the most comprehensive job of explaining the topic explored through this study.

Nature of the Study

The nature of this study was a generic qualitative research design. Generic

qualitative research is appropriate when used to understand an individual’s perceptions

 14
about their experiences (Jahja et al., 2021; Percy et al., 2015). Generic qualitative

research provides flexibility in that it does not conform to the constraints of other

methodologies yet combines elements of other qualitative methodologies to allow the

researcher more flexibility with the design of their research, data collection, and analyses

(Jahja, 2021; Kahlke, 2014; Percy et al., 2015). This qualitative research design was used

to describe the perceptions about and experiences of case managers in human service

organizations related to TIPP. I conducted semistructured interviews with human services

case managers. The research design was appropriate for the extraction of themes found in

the responses of case managers and the commonalities that can be found amongst various

human service organizations.

Definitions

Acute trauma: Trauma from a singular life event such as a death, job loss, or

separation/divorce, or natural disaster (McGonagle & Kessler, 1990; Ross et al., 2021).

Case management: A collaborative process that works to meet the needs of clients

through advocacy, resource management, and communication (Case Management

Society of America, 2021).

Chronic trauma: Prolonged exposure to traumatic events (McGonagle & Kessler,

1990; Missouri Early Care & Education Connections, n.d.; National Child & Traumatic

Stress Network, 2016).

Complex trauma: Exposure to multiple traumatic events sequentially or at the

same time (Missouri’s Early Care & Education Connections, n.d.; Ross et al., 2021).

Retraumatization: Trauma symptoms from a previous traumatic event triggered

 15
by a new situation or event (Alexander, 2012; Butler et al., 2018).

Stress: A psychophysiological response to a real or perceived pressure in the

environment (Piotrowski et al., 2019).

Trauma: An extremely distressing or life-threatening event that causes immense

fear, horror, or helplessness (Kiser et al., 2008).

Trauma-informed policies: System level policies that sets the tone and mission of

the organization so that practices align with an organization’s mission (SAMHSA, 2014).

Trauma-informed practice: The utilization of relational, organizational, and

trauma theory related to the strategies and interventions used in treatment and service

delivery (Bent-Goodley, 2019; Shier & Turpin, 2017).

Assumptions

The first assumption of this study was that participants would openly and

truthfully answer the questions asked in the interview process (Roberts, 2020; Simon &

Goes, 2013). Another assumption was that participants met the criteria of the study if

they indicate that they do. These things require trust between the researcher and the

participants in the study (Wilkins, 2018). The next assumption was that those who

participated in the study would understand what trauma-informed practices and

procedures are and if they were being implemented in their organization(s). It was also

assumed that participants would be comfortable providing sensitive information about

their experiences delivering trauma-informed services and the implementation of trauma-

informed policies in their organizations as well as their perceptions about those

organizational processes and procedures.

 16
Scope and Delimitations

The scope of this study was case managers’ perceptions of TIPP in human service

organizations. Participants were those who were 18 years of age or older; were a case

manager or equivalent position managing the cases of individuals and/or families;

currently, or in the past, have worked in a human service organization that has TIPP in

place; and who read and understand English. Because of the inclusion criteria of the

study, the results of the study could not be generalized to those who would not fulfill

those inclusion criteria. I also did not make conclusions that were outside of the

parameters of the research question, interview questions, or interpretation of the research

in relation to the theoretical framework and literature reviewed as part of the study

(Ankale et al., 2020; Simon & Goes, 2013). I did not ask participants about their

perceptions of training that they received about TIP. Therefore, I did not know the

potential quality of the training that they received about TIP. The scope of the study was

considered when interpreting the data and results as well as recommending future

research and significance of the study.

Limitations

The study was time consuming due to difficulty recruiting participants who met

the inclusion criteria (University of Southern California, 2022). I kept my committee

chair informed of any issues that I had recruiting participants so that we could determine

additional recruitment sites when needed and when it was appropriate for me to stop data

collection. I used snowball sampling to help with this as this recruitment allows for those

who participated (or who saw the recruitment materials) to tell others who may be
 17
interested or meet the criteria.

I did not directly recruit participants who met the inclusion criteria of the study

through human service organizations or emailing them directly. I posted recruitment

materials to social media sites that were human service professional related and included

information that those who saw the recruitment materials could forward the study details

to others. This resulted in purposeful convenience sampling and snowball sampling to be

used for this study. The primary weakness of purposeful convenience sampling is that

research findings are only generalizable to the population characterized by the sample

selection (Andrade, 2020). Snowball sampling is not random, and it is difficult to know

whether the participants reflect an accurate representation of the target population

(Naderifar, 2017; Raina, 2015). Despite the weaknesses of these sampling methods, I

deemed them to be the most appropriate for this study and considered the limitations

generated by utilization of these sampling methods in Chapter 5.

Due to ongoing COVID-19 concerns, I conducted interviews via Zoom. This

could be a limitation as it may have resulted in some potential participants who met the

inclusion criteria for the study to not participate due to technological issues such as

limited internet accessibility. My study results were limited in relation to generalizability

of results based on inclusion criteria used for the study.

Another potential limitation was that I did not ask participants about their

perceptions of training that they received about TIP. Therefore, I did not know the

potential quality of the training that they had received about TIP. However, I asked them

if they had undergone training related to TIP as part of the demographic information that
 18
I collected. I did this so that I would at least know if they had received this type of

training or not as a lens to help interpret the data collection. However, I did not make any

conclusions about the quality of that training in relation to their perceptions about TIP.

This is addressed in Chapter 5 as a potential direction for future research.

Significance

According to the Centers for Disease Control (CDC)-Kaiser ACEs Study (Centers

for Disease Control, 2023), 61% of adults have experienced at least one ACEs. ACEs

include neglect, physical abuse, emotional abuse, sexual abuse, poverty, crime, and

violence (Harvard University, 2021). One in every six adults has experienced four or

more ACEs. My research study has the potential to add to the body of literature relating

to case managers and TIPP within human services organizations. Describing how case

managers perceive TIPP within the organizations they work may help to provide

information on how to prepare case managers to work with victims of trauma and

minimize retraumatization. The results may also be used to help inform training of case

managers on how to best work with clients who have experienced trauma and may also

provide information about human service case managers’ level of preparedness in

working with trauma victims and what other measures they feel can be taken to help them

be better trauma-informed. Information about perceptions of the TIPP within human

services organizations may also help organizations better provide a trauma-informed

work culture for their employees and clients.

Summary

In Chapter 1, I provided an overview of the research study. I discussed

 19
background information on the phenomenon being studied and provided a description of

the theoretical background for this study. I also identified the research problem, the

purpose of the study, and the research question. I provided a brief discussion on the

assumptions, scope and delimitations, the limitations, and the significance of the study.

Finally, I concluded with a summary of Chapter 1. Chapter 2 will provide a more detailed

discussion of the literature and the theoretical framework used to guide my research

study.
 20
Chapter 2: Literature Review

Sixty percent of adults and 60% of those 17 and under have experienced abuse or

witnessed crime, violence, or abuse (North Dakota Department of Human Services, n.d.).

Trauma has been linked with an increased likelihood to suffer from health problems,

mental health issues, substance abuse issues, and financial problems (CNTR, 2020). TIC

and TIP models were created to lessen the possibility of having assistance services result

in more trauma for individuals (Bryson et al., 2017). Though some public systems are

incorporating TIP due to the increased potential for traumatized individuals to be

retraumatized by current standard practices and policies (Loomis, 2018), these may not

be consistent across organizations and services (Carello & Butler, 2015; Hanson & Lang,

2016). The problems that were addressed in this study were the negative repercussions of

retraumatization due to those organizations and systems not being based in trauma-

informed approaches (Ezell, 2019; Huefner et al., 2020; Medenhall et al., 2018; Mersky

et al., 2019; Salloum et al., 2018).

The purpose of this generic qualitative research study was to describe and

understand case managers’ perceptions of TIPP across organizations and services.

Researchers highlighted implementation efforts on TIPP but describing case managers’

beliefs and attitudes about the practices and policies of their organization may help to

inform human service agencies on best practices, policy, and training needs (Bryson et

al., 2017; Ezell et al., 2018). However, further research was warranted that could explore

case managers’ perceptions on TIC, TIP, and trauma-informed policies within their

organizations to address he negative repercussions of retraumatization experienced at the

 21
hands of organizations and systems meant to help victims of traumatic events.

In Chapter 2, I discuss the literature review search strategy for my research study.

I discuss the ecological systems theory which was the theoretical foundation for this

study. I also discuss the literature review related to key terms, variables, and concepts.

Lastly, I provide a summary and conclusion.

Literature Search Strategy

I conducted my literature review search using the Walden University Thoreau

search engine using the following databases: Health Services, PsyBooks, PsyArticles,

APA PsycNet, Criminal Justice, Health and Environmental Research, Health Services

and Sciences Research Resources, Public Administration Abstracts, and SAGE Journals.

I also conducted an internet search through Google Scholar. The key terms included were

ecological systems theory, the ecology of developmental processes, the ecology of human

development, Urie Bronfenbrenner, systems theory, sociocultural theory, field theory,

behavior theory, theory of cognitive development, Jean Piaget, Kurt Lewin, Lev Vygotsky,

sensorimotor approach, microsystem, mesosystem, macrosystem, exosystem,

chronosystem, human services, social services, mental health services, child welfare,

trauma-informed, and trauma. These key terms were used in both the Walden University

Thoreau search and the Google Scholar search. The primary date range used in the

discussion of the literature related to the stated problem was 2015 to the present.

However, I did search for information related to the theoretical framework, EST, back to

the creation of the theory to ensure that I included seminal works about the theory.
 22
Theoretical Foundation

EST was the theoretical framework for this study. EST is used to describe how

social, environmental, political, and cultural systems help to shape human development

(Guy-Evans, 2020). Bronfenbrenner (1979) suggested that how an individual perceives

their environment is important to their behavior and development, which involves

different levels and interactions within and between these levels. Therefore, the theory of

EST was the most comprehensive in explaining case managers’ perceptions of TIPP

across organizations and services to help inform human service agencies (systems) on

best practices, policy, and training needs. EST was appropriate for this study because it

can be used to describe how social, environmental, political, and cultural systems help to

shape human development (Guy-Evans, 2020). EST describes the interactions within and

between each level which individuals may be retraumatized while receiving treatment

(Bronfenbrenner, 1979; Guy-Evans, 2020).

Origin and History

EST was first introduced in 1979 by Urie Bronfenbrenner and includes concepts

that were influenced by Lev Vytgosky’s sociocultural theory, Kurt Lewin’s field theory,

and Jean Piaget’s theory of cognitive development (Bronfenbrenner, 1999). The basic

premise is that an individual’s environment helps to shape their psychological

development including attitudes and behaviors (Lewin, 1946; Piaget, 1976).

Bronfenbrenner (1979) understood that the environmental context of behavior was as

much important to human development as biological factors. The five interrelated

systems (micro-, meso-, exo-, macro-, and chronosystem) were used to explain how
 23
environments affect psychological development.

Components of EST

The components of EST include the individual, microsystem, mesosystem,

exosystem, macrosystem, and chronosystem (Bronfenbrenner, 1977). Figure 1 is a visual

representation of the components (levels) of Bronfenbrenner’s EST. The double arrows

represent the reciprocal relationships between the systems.

Figure 1

Ecological Systems Theory Model

Note. From Bronfenbrenner’s Ecological Systems Theory, by O. Guy-Evans, 2020,

Simple Psychology ([Link]

 24
Individual

The individual is the heart of the EST, and human development is part of a much

larger context known as ecological systems (Martinello, 2020). There is a reciprocal

relationship between all the systems in which the individual belongs as well as those that

the individual has no direct contact (Bronfenbrenner, 1977). The individual has just as

much influence on people and forces within these ecological systems as these people and

forces in the systems have on the individual (Bronfenbrenner, 1979).

Microsystem

The microsystem is a direct environmental setting surrounding the developing

individual. It includes the relationships directly affecting the developing individual such

as those in the home (Bronfenbrenner, 1979; Martinello, 2019). The setting encompasses

place, time, physical features of the setting, activity, participant, and role

(Bronfenbrenner, 1977). Bronfenbrenner (1979) defined the microsystem as the activities,

roles, and relations experienced by an individual. Experience is an important factor

because the perception of events, objects, and the relations experienced by the individual

will shape psychological development (Bronfenbrenner, 1979). Thus, these experiences

give way to some form of communication with the occurring event, object, or person

causing the individual to have influence on the elements within the microsystem. This is

then categorized as reciprocity, which is important to the ecological systems model.

Mesosystem

The mesosystem is a variety of microsystems interacting with one another

(Bronfenbrenner, 1979; Hӓrkӧnen, 2007; Martinello, 2019). The interaction between the
 25
various settings happens when individuals move into a new setting (Bronfenbrenner,

1977). These settings can include the workplace, peer groups, religious groups, social

groups, or associations in the neighborhood (Bronfenbrenner, 1977, 1979). To further

explain the mesosystem, an individual may get a job promotion which causes them to

move into a new position with their employer. This transition is what Bronfenbrenner

(1977) called a role transition and it creates change in the individual’s social position as

well as the setting. Bronfenbrenner defined the change in the new setting as an ecological

transition. The individual becomes the direct connection between two microsystems,

creating a mesosystem (Bronfenbrenner, 1977).

Exosystem

The exosystem refers to the social structures that indirectly influences the

individual’s life (Martinello, 2019). Bronfenbrenner (1977) explained the exosystem as

an extension of the mesosystem. Although the developing individual is not directly

involved within this setting, it affects the immediate environment of the individual

(Eriksson et al., 2018). Two events must take place within the exosystem

(Bronfenbrenner, 1977). In the first sequence, there must be a connection between events

in the outside environment and the microsystem of the individual. Second, processes in

the microsystem must be linked to developmental changes of a person within the setting

(Bronfenbrenner, 1977). An individual’s relations and events at work affect the members

of his family and in turn affect how they respond and behave with one another.

Macrosystem

Macrosystems are institutions or social structures within the society that the
 26
individual lives are representative of a larger society and its belief systems

(Bronfenbrenner, 1979). Society’s rules, laws, and public policies implemented by these

institutions or social structures affect human development (Bronfenbrenner, 1979;

Eriksson et al., 2018). Macrosystems include the beliefs and ideology of a cultural group,

which includes some customs or ideologies that are unspoken but widely practiced

(Bronfenbrenner, 1977). Cultural beliefs, socioeconomic status, and religion have an

impact on the lifestyle and beliefs of an individual and these factors affect the outcomes

within a macrosystem (Bronfenbrenner, 1977). Therefore, the developmental changes

undergone by individuals who are well off differ from those in a low-income family.

Chronosystem

The chronosystem, which was added during the second phase of

Bronfenbrenner’s model, refers to the environmental changes that occur over the

individual’s life (Guy-Evans, 2020). The chronosystem is focused specifically on time

and how relationships can change over time as well as the interaction between systems

over time (Eriksson et al., 2018; Martinello, 2020). The system of time is noted in terms

such as change, time, history, and development and time can cover a short or a long

period (Hӓrkӧnen, 2007). An individual’s beliefs, values, ideologies, organizational

policies, etc. also change over time to reflect developmental change, the acquisition of

knowledge, and growth (Eriksson et al., 2018). As it relates to the individual, time is

subjective and human growth and development is relative to how the individual is

perceiving the event during the moment (Bronfenbrenner, 1977). Whether the event is

ongoing or rapid also impacts how the individual perceives the event taking place in the
 27
system and it is not limited to events happening across the various systems

(Bronfenbrenner, 1977).

Interactions Between Systems

The interactions between each system of the EST are important because they

highlight the ecological orientation from a phenomenological perspective

(Bronfenbrenner, 1979). The most intimate and immediate setting is the microsystem,

meaning the most powerful influence on the individual happens at the microsystem level

(Hӓrkӧnen, 2007). This influence takes place within the family relationship. If one

individual within the environment experiences developmental growth, then so does the

other; there cannot be one without the other (Bronfenbrenner, 1977, 1979). The

reciprocal relationship can further be explained by discussing the relationship between an

individual and their spouse. The family helps to shape growth and development by

influencing each other’s beliefs and behavior (Darling, 2007).

The individual at the center of the setting begins the interaction with other

systems such as their neighborhood, school, family, and religious organizations (Guy-

Evans, 2020). Consider the relationship between an individual and their religious

institution. The relationship between the individual and the church also has a residual

impact on the individual’s relationships with their family. The communication and

interaction between both microsystems form a dual relationship which constitutes a

mesosystem. However, the individual does not have to be present or actively participate

in a setting for it to exert some type of influence over the individual (Bronfenbrenner,

1977, 1979). Therefore, the experience would take place within the exosystem. The
 28
experiences individuals have in the workplace also influence their relationships with their

families (Darling, 2007). Individuals who have demanding work schedules may spend

less time at home. Although this setting does not involve the other members of the

family, there is less time spent with the immediate family. Therefore, the absenteeism of

the individual will ultimately affect how the family interacts with one another.

Bronfenbrenner (1977) knew that these relationships were important to human

development. He went a step further to explain the interactions at the macro level. For

example, an individual who has just given birth at a local hospital is encouraged to bond

with her newborn but is having some difficulties with breastfeeding. Suppose new

policies do not allow for a lactation specialist to support the new mother

(Bronfenbrenner, 1977). Such policies can affect child -rearing. When accounting for the

element of time to this situation, it can change the way the mother and the baby bonds

(Bronfenbrenner, 1977; Darling, 2007). Bronfenbrenner (1979) spoke of time in his early

work, but he did not add the chronosystem until the second phase of EST when he

realized the importance that time plays in the life of the individual and the interactions

with the systems in EST.

Trauma and EST

Trauma occurs when an individual lacks the necessary skills to cope with an

external threat that is overwhelming (Hunter, 2016; Music, 2018). Trauma symptoms

vary and can be the result of biological, psychological, and social factors and any event

causing extreme distress and discomfort can cause trauma (Maercker & Mehr, 2006).

How an individual responds to a traumatic event is relative to their perception of the

 29
event (Withers & Maloney, 2021). These events can include sexual violence, physical

violence, IPV, witness to crimes or violence, natural disasters, accidents, medical

illnesses, death, and divorce among many others (Smith & Patton, 2016).

Trauma and the Microsystem

Trauma relates to the ecological systems theory in the respect that it can be

experienced within, or across, any system that an individual functions within (DeCandia

& Guarino, 2015). Thus, the interactions that individuals have with/within their

environment is a characterization of how individuals experience events in their life (Zhu

et al., 2020). Negative life changing events within the immediate family would disrupt

the microsystem level.

One example of trauma at the microsystem level is intimate partner violence

(IPV). IPV involves violence between two individuals involved in an intimate

relationship (Graham-Kevan et al., 2015). Socio-environmental factors like IPV influence

human behavior and can lead to negative effects (Chesworth et al., 2019). Issues in

physical health, mental health, and behavior are just a few of the negative effects

associated with IPV (Chesworth et al., 2019). Chesworth et al. (2019) and Kiser et al.

(2019) noted that an individual may be at risk for internalizing and externalizing

behaviors which can include trauma symptoms such as depression, anxiety, withdrawal,

antisocial behavior, issues with social relationships, issues with affect regulation, sleep

issues, and cognitive functioning. In addition to IPV, a family with substance abuse

issues, mental health issues, incarceration, and parental-separation or divorce can lead to

trauma as well (Chesworth et al., 2019). These trauma experiences directly affect the
 30
relationships at the mesosystem level.

The immediate family may be a source of retraumatization for the victim as well.

Family support is said to help the individual cope with trauma and reduce trauma

symptoms (Graham-Kevan, 2015; Gibson, 2008). However, when the family is non-

supportive, it can cause retraumatization (Celik et al., 2018). Individuals may recant their

disclosure of abuse or delay their disclosure (Celik et al., 2018). Researchers state that

family rejection and denial are responsible for recantation or delayed disclosure putting

them at risk for revictimization (Celik et al., 2018).

Trauma and the Mesosystem

When encountering systems at the mesosystem level, individuals of IPV may

have negative experiences seeking services to assist them (Guy-Evans, 2020; Zhu et al.,

2020). For example, a victim of IPV may seek services from the legal system. Court

proceedings often become very adversarial because the victims often face questioning

that feels accusatory (Katirai, 2020). Victims’ decisions and actions during IPV can be

used against them by their perpetrator’s attorney. This process causes retraumatization

and victims may choose to forgo court proceedings (Katirai, 2020). It was also reported

that the victims may choose to stop disclosing due to the attitudes of the service providers

(Katirai, 2020). Even attempting to access services such as finding shelter can be

retraumatizing. The victim of IPV may feel stigmatized by having to live in a shelter and

the process of registering for shelter services may feel invasive. These experiences affect

the way the victims see other agencies in their community. They have difficulty trusting

other service providers based on previous experiences (Klest et al., 2019).

 31
Family courts also allow perpetrators to have a relationship with their children

(Roberts et al., 2015). This puts the victim at direct risk for revictimization even if a

protective order is in place (Roberts et al., 2015). Roberts et al. (2015) noted that 70% of

protective orders are breached, less than 10% percent of cases are prosecuted, 51% of

victims are revictimized within ten weeks after leaving a shelter, and 30% of women are

killed by their perpetrator after separating.

Trauma and the Exosystem

Negative interactions with the media (including social media), government

agencies, and other organizations and systems at the exosystem level also have the

potential to result in trauma to the individual (Guy-Evans, 2020). Media becomes a part

of the exosystem (individual is not a direct participant) in that it infiltrates the home via

various external methods (Bronfenbrenner, 1979). Individuals may consume media by

television, radio, social media apps, newspapers, journals/magazines, and/or the internet.

The information consumed affects the consumer which then has influence on the

immediate family (second-order effect) (Bronfenbrenner, 1979). It has also been noted

that PTSD is known to be the common negative repercussion of exposure to mass media

violence (Neria & Sullivan, 2011). Symptoms of PTSD include but are not limited to

recurrent nightmares, exaggerated startle response, avoidance of reminders, and numbing

(Neria & Sullivan, 2011).

Regarding the example of IPV, media can influence how individuals perceive

intimate partner violence because the public has largely relied on the media to understand

IPV as a social issue (Carlyle et al., 2014). Men are characterized as naturally aggressive
 32
and women who perpetuate IPV are justified for their behavior (Carlyle et al., 2014).

These characterizations of IPV further creates the notion that women IPV perpetrators

must be responding to violence perpetuated against them first. However, this leaves male

victims with feelings of shame, embarrassment, depression, anxiety, poorer reported

health status, and isolation from social networks (Carlyle et al., 2014). Researchers have

supported the claim that men experience more restrictions to services due to stigmas that

do not characterize men as victims of IPV (Carlyle et al., 2014).

Trauma and the Macrosystem

The attitudes and ideologies at the macrosystem level are reflective of the culture

of larger organizational systems. Experiences with certain cultural groups have the

potential to result in trauma and retraumatization (Hӓrkӧnen, 2007). Public policies and

laws are designed to influence change at the micro-, meso-, and exosystem levels and

activism can influence the policies created at the macrosystem level which should trickle

down to all the levels below the macrosystem. However, inconsistencies and conflicting

policies can result in retraumatization.

Immigrant women who experienced IPV have been found to make decisions

about how to deal with the IPV based upon the accurate or misinformation of

immigration rules and policies (Alaggia et al., 2012). Immigration policies may not be

designed with the thought of mitigating factors that lead some individuals to have contact

with immigration services (Alaggia et al., 2012). The perpetrator of the IPV may use

their non-citizen status as a scare tactic to keep control of their partner. The women may

also be fearful that they would become the subject of a child welfare investigation
 33
(Alaggia et al., 2012). Again, their spouses or partners would also threaten to call child

welfare as means of control (Alaggia et al., 2012).

Trauma and the Chronosystem

The chronosystem is representative of time which plays a pivotal role in the

effects of trauma over time, traumatic experiences being repeated, and how one heals

(Carlson & Dalenberg, 2000; Hӓrkӧnen, 2007). Kiser et al. (2008) explained that people

understand traumatic events in terms of the time before and after the event. Trauma can

happen as a single event in time, multiple events on separate occasions, multiple events in

one moment, or a single event/multiple events happening over a longer span of time

(prolonged exposure to trauma) (Kiser et al., 2008). The consequences of prolonged

exposure to trauma can include dissociative symptoms, reenactment and revictimization,

suicidality, psychosomatic symptoms, and affective and anxiety disorders making trauma

from prolonged exposure much more complex (Neria & Sullivan, 2011).

Time is also relevant to how an individual sees the future as well. It is not

unlikely for individuals to feel hopeless and pessimistic about the future. Prolonged

trauma leaves an individual unable to think beyond where they are in the moment,

leaving them to think only of surviving (Warmingham et al., 2021). The brain is in a

constant state of survival mode which leaves the individual unable to make rational and

logical decisions (Warmingham et al., 2021).

IPV victims may endure prolonged exposure to trauma causing changes in their

emotional states or thinking (Pill et al., 2017). Negative moods/states or thinking styles

affect how individuals perceive the treatment that they receive when seeking services
 34
(Graham-Evan et al., 2015). Newgent et al. (2003) pointed out that individuals may

potentially decline to put themselves through the system because it is not beneficial to

them and called this experience a “second insult.” IPV survivors may need to seek child

custody, child support, an order of protection, or even divorce (Katirai, 2020,). This

experience of having to face their abuser in court can be retraumatizing to the victim.

Victims may have their character questioned in a trial. Having a judge that lacks empathy

and compassion for these victims can cause undo harm and retraumatization as well.

Such lack of compassion and empathy results in victim blaming. IPV victims may not

report to law enforcement due to unwarranted skepticism, gender bias, minimization,

victim blaming, and sexual shaming. These determinants are reported to cause

retraumatization (Decker et al., 2019).

Retraumatization

Individuals can be retraumatized by another traumatic or stressful event

experienced within any level of ecological systems (Gibson, 2008). Retraumatization can

also happen when they encounter a negative experience with the system (criminal,

medical, mental health, family, social services, etc.) that they go to for help (Katirai,

2020; Newgent et al., 2003). Victims of traumatic events often find themselves met with

attitudes, behaviors, and practices that project blame onto them instead of those that they

were victimized by (Katirai, 2020). These actions may not be intentional, but they cause

more harm to the victims.

IPV victims who are not believed sometimes recant leaving them vulnerable to

revictimization (Newgent et al. 2003; Celik et al., 2018). Non-belief or support can
 35
signify a second insult to victims resulting in decreased emotional stability and victims

need social support to buffer trauma symptoms (Graham-Kevan et al., 2015). Outside of

non-support or belief, the family members in the immediate setting may experience

secondary trauma. This can be detrimental to the immediate family. IPV victims also

reported feeling betrayed by the system, not taken seriously, degraded, and a loss of hope

(Pratt-Eriksson et al., 2014). If victims do go through with reporting their abuse, the

service providers that provide services to the victims can unintentionally retraumatize the

victims.

The adversarial nature of court proceedings can also be retraumatizing to the

victims (Katirai, 2020). Victims whose cases are dropped because of lack of evidence

feel unheard and it was characterized as a new assault (Pratt-Eriksson et al., 2014).

Victims feel forced to have to defend their need for sick leave to healthcare professionals

and the legitimacy of their abuse to law enforcement (Pratt-Eriksson et al., 2014).

Although perpetrators are aggressive, some victims are forced to have their children

continue the relationship with the other parent (Roberts et al., 2015). Each of these

injustices are being carried out at the mesosystem level.

During the discussion of trauma at the exosystem level, it was noted how the

media frames IPV directly influencing the perceptions the public have on IPV (Carlyle et

al., 2014). Not only has the media infiltrated the homes of the public, but it has also may

cause the individuals in that home to formulate a perception of IPV. These two

phenomena are simultaneously affecting the microsystem, mesosystem, and the

exosystem (Bronfenbrenner, 1979).

 36
Public policies at the macrosystem level reflect the ideologies and attitudes of

larger organizations (Bronfenbrenner, 1979; Eriksson, 2018). In reference to immigration

policies and child welfare, it was noted that children had been removed from the home in

certain situations and undocumented immigrants feared deportation if they reported

(Alaggia et al., 2012). The fear of children being removed from the home and deportation

creates this cycle of continued abuse because some victims do not want to risk reporting

(Alaggia et al., 2012. Therefore, they stay in abusive cycles and continue to be

revictimized by their perpetrators. Instances where child welfare does become involved

can further traumatize the children especially if they are removed from the home

(Alaggia et al., 2012). Families become distrusting of the systems designed to protect

them.

As it relates to the chronosystem, time seems to stand still for IPV victims and

they feel that they are constantly reliving their abuse (Roberts et al., 2015). Multiple or

ongoing trauma will affect everyone differently because it is subjective (Bronfenbrenner,

1979). The negative repercussion of ongoing trauma is more pervasive in that it may

cause dissociations (Neria & Sullivan, 2011). A parent trying to protect themselves and

their children from the perpetrator and the system may find themselves in survival mode

leaving these individuals feeling hopeless about their future (Pratt-Eriksson et al., 2014;

Warmingham et al., 2021).

Literature Review Related to Key Variables and Concepts

In the following sections, I discussed stress and the psychological impacts of

stress. I discussed the trauma individuals sustain as a result of such stress. I provided a
 37
summary of the various types of trauma, the prevalence of trauma, and how trauma

affects brain development. Finally, I discussed the types of organizations that provide

services to individuals of trauma and the reasons individuals may need to seek services

from those organizations.

Stress

Stress is a psychophysiological response to a real or perceived pressure in the

environment (Piotrowski et al., 2019). A prolonged exposure to stress can cause

hormonal imbalances, weakened immune system, and an increased risk of cancer,

disease, and death (Piotrowski et al., 2019). However, stress is a normal part of

development (Auerbach & Miller, 2021). Individuals most often experience stress from

daily tasks such as jobs, relationships, and living circumstances (Auerbach & Miller,

2021).

Individuals usually take some action to mitigate or eliminate that stress as it is an

uncomfortable feeling (Auerbach & Miller, 2021). A positive mindset can help to

mitigate stress. Individuals utilize it to turn stressful situations into learning moments

(Luu, 2022). Family and social support helps individuals to develop coping strategies to

combat stress. Family may also provide financial resources during hard times or

compassion and empathy for emotional support. Individuals with social support are said

to cope better than those who lack social support (Luu, 2022).

Stress is most often associated with fear and anxiety. Fear and anxiety are terms

used interchangeably (Auerbach & Miller, 2021). However, some researchers maintain

that the two are not interchangeable and there are stark differences between the two (Aly
 38
& Green, 2010; Schulz, 2006) while other researchers noted that the two terms were

ambiguous (Perusini & Fanselow, 2015). Anxiety relates to the emotional state that

occurs when stress occurs (Auerbach & Miller, 2021; Schulz, 2006). Anxiety is a feeling

of dread which could be considered a precursor to fear (Aly & Green, 2010). Fear is a

response of imminent danger and is more pronounced than anxiety (Aly & Green, 2010).

Trauma

Trauma is an extremely distressing or life-threatening event that causes immense

fear, horror, or helplessness (Kiser et al., 2008). Trauma happens when an individual is

exposed to an external threat and is unable to cope with having experienced that threat

(Bloom, 1999). Trauma changes the way one thinks, feels, remembers, learns, and makes

sense of the world because it interferes with brain functioning (Bloom, 1999; Van der

Kolk & Saporta, 1991). Part of understanding trauma is understanding that trauma can be

caused by any type of event and what may be traumatic to one individual may not be

traumatic to another (SAMHSA, 2014). This is because how the individual perceives the

experience is what determines if it will be traumatic to the individual or not. The factors

that affect the individual’s perceptions are characteristics of the individual, the type and

characteristic of the event, developmental processes, the meaning of the trauma, and

sociocultural factors (SAMHSA, 2014).

Trauma is very much different from stress, anxiety, and/or fear in that it can be

the result of one extreme situation and often results in long lasting negative effects (Van

der Kolk & Saporta, 1991). Trauma is a more extreme response to a life-threatening event

than just stress, anxiety, and/or fear and the threat to life does not have to be towards the
 39
individual. It may be in relation to seeing the life-threatening experience that someone

else experiences (Australian Institute of Health & Welfare, 2020). However, trauma can

result from the experience of stress and anxiety. When symptoms of stress persists at

least several weeks or longer and interferes with the individual’s personal, family, social,

occupational, or educational functioning, it can develop into trauma and possibly PTSD

(Australian Institute of Health and Welfare, 2020).

Prevalence of Trauma

NCBH ( n.d.) found that 70% of the U. S. population have experienced at least

one trauma in their lifetime. In addition, 90% of clients in public behavioral health

programs have experienced trauma and 60% of men and 50% of women will experience

at least one trauma in their lifetime (NCBH, n.d.; U.S. Department of Veteran Affairs,

n.d.). Trauma results in outcome that costs the United States $458 billion per year

(Berger, 2019; CDC, 2023). Researchers have also found a direct link between trauma

and diabetes, high blood pressure, heart disease, cancer, and chronic obstructive

pulmonary disease (NCBH, n. d.).

The most common traumas experienced by women and youth in the U.S. are

sexual assault and child sexual abuse (APA, 2021; U. S. Department of Veteran Affairs,

n.d.). Men and boys are more likely to experience trauma related to accidents, physical

assaults, combat, disaster, or witnessing death or injury (APA, 2021; U.S. Department of

Veteran Affairs, n.d.). Racial and ethnic minority groups and families and immigrant

youth and families are more likely to experience trauma due to poverty and

discrimination (APA, 2021).

 40
Types of Trauma

Acute Trauma. Acute trauma is trauma from a singular life event such as a death,

job loss, or separation/divorce, or natural disaster (McGonagle & Kessler, 1990).

Individuals are likely to recover more quickly after acute traumas than chronic traumas

(Keller-Dupree, 2013). Acute trauma has been known to increase corticosteroid levels

which can impair cognitive functioning causing individuals to have decreased memory

and attention (Bogdanov et al., 2021; Vedhara et al., 2000).

Chronic Trauma. Chronic trauma is prolonged exposure to traumatic events

(McGonagle & Kessler, 1990; Missouri Early Care & Education Connections, n. d.;

National Child & Traumatic Stress Network, n. d.). Financial difficulties due to job loss,

prolonged abuse, marital problems, and poverty are all considered chronic trauma

(McGonagle & Kessler, 1990; Missouri’s Early Care & Education Connections, n.d.;

Yale Medicine, 2021). These ongoing experiences of trauma can be a predictor of

negative psychological adjustment as it is persistent (McGonagle & Kessler, 1990).

Complex Trauma. Complex trauma is exposure to multiple traumatic events

sequentially or at the same time (Missouri’s Early Care & Education Connections, n. d.).

Complex trauma is often ongoing, difficult to escape, occurs within a personal

relationship, begins in childhood, and is kept secret (International Society for the Study

of Trauma and Dissociation [ISSTD], 2020). Complex trauma changes the brain structure

because it most often happens during childhood during critical points of brain

development. The critical moments of development occur during the formative years (0-8

years of age) and trauma in the formative years most often involves someone with a
 41
position of power or someone the child trusts (ISSTD, 2020). Examples of complex

trauma are abuse, sex trafficking, domestic abuse, sexual abuse, and ongoing torture

(ISSTD, 2020).

Trauma and Brain Development

Trauma can happen at any point in an individual’s life, but ACEs can continue to

affect individuals as adults (Van der Kolk, 1991). Poor school performance, lower

reading achievement, and decreased verbal IQ can be carried into adulthood and have

been found to be related to ACEs (Carrion & Wong, 2012). Part of the reason behind this

is that trauma during childhood (developmental years) can cause developmental delays

and physical change to how the brain works.

The prefrontal cortex, amygdala, and the hippocampus are three structures in the

brain that are affected by trauma (see Figure 2; Carrion & Wong, 2012; McLaughlin,

2014). The amygdala is responsible for detecting and responding to threats in the

environment. When activated, individuals can become more aware or hypervigilant to

reminders of the trauma. The prefrontal cortex is also responsible for helping to control

the reactions of the amygdala. However, the prefrontal cortex may not work properly due

to trauma leaving children with pervasive fear and anxiety.

 42
Figure 2

Brain Diagram

Note. From “Adverse Childhood Experiences and the Developing Brain,” by E. Lewis,

2019, National Centre for Mental Health ([Link]

childhood-experiences-and-the-developing-brain/)

The hippocampus is responsible for learning and memory (Perry et al., 1995;

McLaughlin, 2014). Trauma to the hippocampus at such a critical time of development

affects how children learn and remember information in their environment (McLaughlin,

2014). Small hippocampus volume has been associated with individuals with depression

(Majer et al., 2010). Given such, researchers have linked early adverse childhood

experiences to psychiatric and somatic disorders in adulthood (Huang et al., 2021; Majer

et al., 2010). The prefrontal cortex, amygdala, and hippocampus are most affected by

trauma (Carrion & Wong, 2012; McLaughlin, 2014). Trauma is associated with

diminished brain functioning due to the inability to regulate emotions and a heightened

sense of danger.

Figure 3 is a visual representation of what the trauma in those areas looks like on
 43
a positron emission tomography scan (Lyons et al., 2018). The prefrontal cortex is

located at the front of the brain. The brain on the left shows high activity in the prefrontal

cortex as evident in the red and yellow colors on the scan as opposed to the brain of

someone who experienced abuse on the right. The brain of someone who experienced

abuse shows more green and yellow color which signifies less activity than the healthy

brain. The purple and black areas are the least active areas in the brain of someone who

has experienced abuse. The brain on the right shows little to no activity in the area

(temporal lobes) of the brain that regulates emotion and receives input from the senses

(Lyons et al., 2018). The areas of the brain most responsible for performance and

achievement, emotional regulation, and memory are the areas with decreased functioning

as represented in the abused brain.

Figure 3

Healthy and Abused Brain

Note. From Report of Act 43 Legislative Working Group for: Childhood Trauma/ACEs,
 44
by G. Lyons, B., Balint, D. Soucy, A. Donahue, K. Webb, & M. Mrowicki, 2018.

([Link]

Trauma and Emotions

The formative years are a critical time of cognitive, social, emotional, and

physical development and it ranges between the ages of 0-8 years of age (Lewis et al.,

2006). Trauma during the formative years can cause significant distress because children

are unable to properly regulate their emotions (Hunter-Dehn, 2021). Because children

have difficulty identifying and understanding their emotions, they become unable to

correct the maladaptive behavior(s) (Hunter-Dehn, 2021). Consequently, they may

respond to distressing situations by acting out, with aggression and defiance, and mood

swings (Hunter-Dehn, 2021; Webb, 2016). Some children may also experience

dissociations which are defense mechanisms or a protective factor for trauma.

Dissociation involves disengagement, withdrawal, and daydreaming which are

characterized as negative repercussions of trauma (Hunter-Dehn, 2021). These negative

repercussions also include intrusive thoughts/recollections, hypervigilance, exaggerated

startle, dissociation, mood disturbances, psychological reactivity to reminders,

physiological reactivity to reminders, and distorted cognitions amongst many other

symptoms (Hunter-Dehn, 2021). Between 12-29% of clients in outpatient clinical settings

have been found to experience dissociation (Sook Kong et al, 2018).

Emotional abuse was found to be a predictor of hyperarousal and intrusion

symptoms in adults (Lewis et al., 2006). Avoidant symptoms have also been found to be

consistent with the victims’ ongoing psychological abuse (Lewis et al., 2006). The
 45
severity and length of the traumatic experience has been found to influence the long-term

trauma symptoms (Evans et al., 2014).

Betrayal trauma occurs when there is prolonged trauma against a child by a parent

or other authority figure that should love the child (McCormack & Issakidis, 2017).

Betrayal trauma often leads to feelings of abandonment and distrust (McCormack &

Issaakidis, 2017). Researchers found that 63% of the children (2.5 to 7.5 years of age)

have insecure attachments with their mothers or caregivers (Hornor, 2008). Attachment

issues have also been found to be much higher in high-risk populations (Hornor, 2008).

Researchers further discovered that mothers who had been abused in childhood had

difficulty with negative emotions and providing feelings of security to their children

(Koren-Karie et al., 2004). The children then adjusted their feelings to fit the emotional

level of the parent (Koren-Karie et al., 2004). Therefore, childhood trauma affects

emotional regulation in children and adults, and it affects adult trauma victims’ ability to

effectively parent and provide a sense of belonging, self, and sense of emotional security

to their children (Koren-Karie et al., 2004). This further demonstrates a pervasive cycle

of emotional dysregulation within families.

Retraumatization

Retraumatization happens when victims experience trauma symptoms from a

previous traumatic event triggered by a new situation or event (Alexander, 2012).

Retraumatization is related to poor treatment outcomes and more severe symptoms found

to be related to trauma (Lawson et al., 2020). The timing of subsequent traumas and the

type of traumatic event has an impact on whether the individual feels retraumatized.
 46
Individuals who experience trauma in childhood are at an increased risk of being

retraumatized in adulthood (Lewis et al., 2006; Matta Oshima et al., 2014). Interpersonal

difficulties put individuals at a greater risk for sexual and physical retraumatization

(Deitrich, 2007; Matta Oshima et al., 2014). Individuals also run the risk of

revictimization due to their inability to identify and cope with dangerous situations

(Deitrich, 2007).

Retraumatization has also been found to be higher in individuals of color (Butler

et al., 2018). Environmental factors such as poverty, crime, and family violence are

factors that increase the risk of retraumatization (Klest, 2012). In addition to

environmental factors, individuals run the risk of being retraumatized due to personal

characteristics that mark them as easy prey or targets of peer bullying reinforcing

retraumatization in the same manner as the previous incident (Brendgen et al., 2019).

Retraumatization by Social Structures and Processes. Trauma victims can

sometimes feel a loss of control, power, or safety during a traumatic event (Boulder

County DA’s Center for Prevention and Restorative Justice, 2019). Systems that recreate

this feeling or environment retraumatize victims (Newgent et al., 2003). Victims can feel

traumatized due to the response they may receive from victim serving agencies

(SAMHSA, 2014). It is important for these agencies to learn how to support those victims

in a trauma-informed manner (Newgent et al., 2003).

One way that systems retraumatize is by not providing the necessary resources to

support victims of trauma (Zgoda et al., 2016). The mental health system is important to

victim recovery. Many victims who experience abuse during childhood most often have
 47
difficulty trusting as adults. The process of forming the therapeutic alliance can be

triggering or retraumatizing because it encourages a relationship of trust which is most

often associated with their abuse (Lawson et al., 2020). As mentioned previously, child

abuse most often involves a person of power/personal relationship (ISSTD, 2020).

The lack of knowledge, awareness, and training are elements in the healthcare

system that may perpetuate retraumatization (Schippert et al., 2021). Dallam’s healthcare

retraumatization model explains the retraumatization process through four sub-processes:

1) hypersensitivity to threats to safety; 2) exposure to triggers; 3) post-traumatic stress

reactions; and 4) avoidant coping (Schippert et al., 2021). Hypersensitivity to threats to

safety encompasses the feelings of distrust, vulnerability, powerlessness, loss of control,

low self-esteem, and difficulty self-advocating that victims experience while seeking

services in the healthcare system (Dallam, 2010). These feelings are evident of trauma

and are recreated when individuals are triggered (Dallam, 2010). Exposure to triggers in

the healthcare setting may be any stimuli and/or situation that remind an individual of

their abuse. Once an individual is triggered, they may experience stress reactions

characterized as emotional and physical distress (flashbacks, anxiety, and/or panic) which

are described as post-traumatic stress reactions in the Dallam’s healthcare model

(Dallam, 2010). Individuals will usually find a way to mitigate or alleviate their stress

through denial, dissociation, submission, hostility, numbing, and/or healthcare avoidance

(Auerbach & Miller, 2021; Dallam, 2010). This cyclical process may cause individuals

not to return for services which can be characterized as an avoidant coping mechanism

(Dallam, 2010; SAMHSA, 2014; Schippert et al., 2021).

 48
There are numerous ways that the environment, processes, and systems that are in

place can result in retraumatization. Various sensory stimuli within a healthcare setting

may remind the victim of stimuli from the traumatic event (Dallam, 2010; SAMHSA,

2014). Medical treatment can seem invasive and resemble the loss of control victims

experience during traumatic events (Schippert et al., 2021). Victims who experience

anxiety due to retraumatization are more likely to avoid doctors and medical settings

(Schnur et al., 2017).

Child welfare systems and juvenile justice systems may elicit painful physical

reminders of trauma previously experienced for both parents and the child (Crenshaw et

al., 2019; Lamminen, 2020; Smith & Bowman, 2019). Juveniles have recalled their

experiences of being restrained in the juvenile justice system as scary, hurtful, and it

reminded them of other negative experiences (Smith & Bowman, 2019). These are

indicative of retraumatization (Alexander, 2012; SAMHSA, 2014). For children in child

welfare systems, the act of being removed and placed in multiple foster care homes can

be a reenactment of the initial removal from the home with their parent or caregiver

(Miller et al., 1981). This experience can be retraumatizing.

Even organizations who are responsible for getting information out to the public

may unwittingly add to the potential for retraumatization. The media perpetuates rape

culture by portraying rape victims as responsible for their rape (Zgoda et al., 2016). Rape

victims may feel reluctant to come forward and potentially experience retraumatization

because of this messaging. Thus, victims blame themselves and help-seeking behaviors

decrease in response to cultural stigmas (Dodd et al., 2021). If victims choose to continue
 49
with legal prosecution, they may experience retraumatization due to the adversarial

nature of court proceedings (Katirai, 2020). Victims may be reluctant to report or they

forgo prosecution to avoid humiliation and ridicule throughout the court process (Katirai,

2020).

Human Services

Human Services encompasses a very broad field and is divided into three main

sectors: nonprofit or Non-governmental organizations; governmental or public entities;

and private sectors (Human Services Edu, n.d.). These organizations aim to improve the

quality of life through improved service delivery, accessibility of services, accountability,

and the coordination of services with other agencies (Human Services Edu, n.d.). They

also focus on prevention and the mitigation of problems such as poverty, housing

insecurity, and food insecurity (National Organization for Human Services, n. d.).

Types of Services Provided

The field of human services covers a large umbrella of services ranging from

healthcare and counseling services to food and shelter (Human Services Edu, n.d.; Martin

& Haslett-Knudsen, 2012). The human services field is divided into three main sectors of

nonprofit or non-governmental organizations , governmental or public entities, and

private sector organizations (Human Services Edu, n.d.). Within these sectors are

specialized fields such as education, healthcare, behavioral/mental health, social services,

income maintenance, employment training, rehabilitation, housing, recreation, and social

development (Kramer, 2000). Some human service agencies provide financial services

based on economic status while others may provide mental health services, food
 50
assistance, protection from abuse, protection orders, and services for individuals with

physical disabilities (Martin & Haslett-Knudsen, 2012). Human service agencies also

design their services to help individuals find employment, housing and shelter, safety and

disaster relief, and youth services (Moffat, 2011). These agencies often perform services

with limited resources, limited providers, and limited funding (Kilwein & Smith, 2013).

Nonprofit/Non-governmental Organizations. Non-profit agencies have a

mission to fulfill a specific need within their communities or society and they contract

with public agencies to deliver those services (Despard, 2016). They are often dependent

upon outside sources and donors to help sustain their organization (Despard, 2016). Non-

profit organizations are organizations such as the American Red Cross, food banks,

battered women shelters, etc. The American Red Cross provides resources for individuals

and families affected by disaster, and they help prepare communities for disaster

including coordinating blood donations (The National American Red Cross, 2022). Food

banks distribute food to community food pantries which provide food to families in their

communities (Feeding America, 2022). Battered women shelters provide shelter in an

undisclosed location to help protect battered women from their abuser as well as other

crucial resources such as counseling (Healthy Place, 2022).

Governmental/Public Entities. Governmental agencies are the largest sector of

human service organizations, and they are backed by government funding (Human

Services Edu, n.d.). Some governmental agencies that are considered human service

organizations are the Department of Health and Human Services (HHS), U.S. Public

Health Service, Department of Mental Health, Department of Youth Services, and the
 51
Department of Justice (U.S. Department of Health and Human Services, 2015). These

agencies have other entities underneath their umbrella of services that deliver direct

services to the community.

State welfare agencies also fall underneath HHS. State welfare organizations are

responsible for ensuring social well-being for children, families, individuals, and

communities (DHR, n.d.). They are responsible for providing the elderly, individuals

with disabilities, and children with protection from abuse, neglect, and exploitation. They

are responsible for maintaining a registry for child abuse and neglect and managing cases,

caseloads, and various other services (Alabama Department of Human Resources, n.d.).

State welfare agencies are also tasked with providing access to state benefits for qualified

individuals (U.S. Department of Health and Human Services, 2015). This includes state

Medicaid and Medicare benefits, Supplemental Nutrition Assistance Program , Women’s,

Infants, and Children Program , child/elder abuse protection and prevention, and

Temporary Assistance for Needy Families (U.S. Department of Health and Human

Services, 2015).

The Substance Abuse Mental Health Services Administration (SAMHSA) is

responsible for improving the lives of individuals and their families by mitigating the

effects of mental health issues and substance abuse disorders (SAMHSA, 2021). The

state levels of this mental health agency are responsible ensuring the mental health and

well-being of individuals with mental illnesses, developmental disabilities, and substance

abuse issues by providing mental health counseling and evaluations, substance abuse

counseling programs, and rehabilitation services (Alabama Department of Mental Health,

 52
n.d.). State mental health departments and private mental health professionals have the

duty of supporting clients through the healing process. Mental health professionals foster

a therapeutic relationship with their clients to build trust, respect, and honesty (Alabama

Department of Mental Health, 2021).

The U.S. Department of Justice is responsible for protecting the safety of the

public (U.S. Department of Justice, n.d.). State district attorney offices are often in

contact with victims as they prosecute alleged perpetrators (Legal Information Institute,

2021). The district attorney’s office may connect victims with other community resources

to help meet their needs. They also provide a victim services officer to support the

victims through the court process as well as communicating to them their victim rights

(Montgomery County District Attorney’s Office, 2021). The office may help them seek

restitution due to injuries or expenses sustained due to their victimization (Montgomery

County District Attorney’s Office, 2021). The Office of Juvenile Justice and

Delinquency Prevention serves states, local communities, and tribal communities by

providing services to youth and their families (OJJDP, n.d.). They advocate for youth

who have been victimized and aim to prevent juvenile delinquency. One way this is

accomplished is by implementing policies at the federal level (OJJDP, n.d.).

Private Sector Organizations. Private sector organizations are not dependent

upon donor funding and often offer the most competitive salaries as they may charge the

user (or contracting group) for their services (Zelnick & Abramovitz, 2020). Due to

increasing demand to provide much needed services to communities, private sector

companies are being sought after to provide services to the public to the point that some
 53
governmental agencies have begun contracting out their services to fill a gap (Sanger,

2001). State welfare agencies contract with private mental health providers to provide

counseling for their clients, child support enforcement, and larger health insurance

companies have contracted with states to provide their state Medicaid (Nutt, 2006;

Waldman, 2012). It appears that the types of services rendered are comparable to non-

governmental organizations and governmental/public organizations, but private sector

organizations may be able to meet more of the demand as they are better able to hire

professionals to meet the needs of the number of users of their services (Zelnick &

Abramovitz, 2020).

Human Services Case Managers

Case management is a collaborative process that works to meet the needs of

clients through advocacy, resource management, and communication (Case Management

Society of America, 2021). Case managers aim to recommend and deliver services to

meet the needs and improve the quality of life of those that they work with (American

Case Management Association, 2020; Commission for Case Manager Certification,

2022). The philosophy of case management is derived from the idea that everyone

benefits when clients are freely able to maintain autonomy, self-management, and reach

their peak state of wellness (American Case Management Association, 2020). Case

managers are an intricate piece to the services clients receive because they can link them

with vital resources (Stanhope et al., 2009). Case managers also make sure that provided

services are safe, effective, client-centered, and efficient (Case Management Society of

America, 2021; Commission for Case Manager Certification, 2022). A part of their role is
 54
also to assess and monitor the progress of their clients (Alabama Department of Human

Resources, n.d.).

Clients Served by Human Service Organization/Programs

Financial Assistance. Individuals with low to moderate income often rely on

human service organizations to help with financial stress (Frey et al., 2017).

Environmental factors such as poverty would warrant an individual to seek out financial

assistance to obtain financial stability (Tretheway, 1997). Temporary Assistance for

Needy Families is a federal program that aids needy families in gaining financial

stability (Xu et al., 2020). Temporary Assistance for Needy Families is money

distributed to low-income families through state welfare agencies (Office of Family

Assistance, 2022).

Non-profit organizations, like Catholic Social Services, aim to deliver a myriad of

services to individuals in need, but financial assistance is a common service that they

provide (Catholic Social Services, n.d.). Emergency financial assistance is provided to

pay for utilities, rent, transportation, and medicine (Catholic Social Services, n.d.). Evans

et al. (2019) teamed up with Catholic Social Services to administer an emergency

financial assistance program to college students. They found that programs were not as

effective without a case manager to help address underlying issues of financial stress

(Evans et al., 2019). Case managers are better able to identify needed services and act as

an intermediary between the client and the provider (Case Management Society of

America , 2021).

Housing Assistance. There are many reasons why individuals may need housing
 55
assistance, but approximately 3.5 million Americans experience homelessness each year

(Morris & Strong, 2004). The U. S. Department of Housing and Urban Development

distributes funds through public housing agencies to help combat homelessness and

provide rental assistance to low-income families (U. S. Department of Urban and

Housing Development, n.d.). Individuals can apply for public housing or housing choice

vouchers (Section 8) which are not limited to public housing (U. S. Department of

Housing and Urban Development, n.d.). The U. S. Department of Agriculture (USDA)

(n.d.) works with public and nonprofit organizations to provide housing assistance in

rural areas. They also work with private lenders to ensure loans for borrowers (USDA,

n.d.).

Housing assistance such as transitional housing and rapid rehousing are just a few

of the programs offered through nonprofit agencies family and individual needs through

federal funding (Family Sunshine Center, n.d.). Transitional housing is utilized to help

integrate clients back into the community while they receive additional support services

such advocacy, counseling, life skills, and case management. Rapid rehousing is

immediate placement into permanent housing if they have no other safety concerns

(Family Sunshine Center, n.d.).

Individuals may not be familiar with the processes or know how to access housing

services, which makes case management even more important (Morris & Strong, 2004).

Case managers are considered frontline workers in human services organizations because

they bear the responsibility of identifying housing programs and keeping individuals and

families engaged in the services (Stanhope et al., 2009). Stanhope et al. (2009) noted that
 56
prior abuse and trauma affected the mental health of individuals and their engagement in

services. Case managers are tasked with anticipating consumer behavior in order to

prevent disengagement (Stanhope et al., 2009).

Food Assistance. Food insecurity is an issue of poverty that both rural and urban

areas continue to experience (Piontak & Schulman, 2014). The USDA (n.d.) offers

programs such as the Supplemental Nutrition Assistance Program (formerly known as the

Food Stamp Program), Special Supplemental Nutrition Program for Women, Infants, and

Children , and the Summer Food Service Program to combat food insecurity. The

Supplemental Nutrition Assistance Program and Women, Infant, and Children’s WIC

benefits are delivered through state human service agencies, but individuals have to meet

certain income criteria to qualify (Alabama Department of Human Resources, n.d.;

USDA, n.d.). State human services agencies employ case managers to determine one’s

eligibility for these food assistance programs and to follow up for recertification. Those

individuals who do not qualify for these federally funded programs are left to find other

programs to help with food assistance.

In such cases, case managers are an intricate part of navigating resources because

they are often the individuals responsible for eliminating the barriers to the access of

services (Case Management Society of America, 2021; Stanhope et al., 2009). Case

managers may direct individuals to local food pantries. Feeding America is a 200-

member organization that distributes food to over 60,000 food pantries nationwide

(Feeding America, 2022). Food insecurity affects children, the elderly, and people of

color at higher rates than other groups due to systemic inequities, socioeconomic status,
 57
intimate partner violence, and mental health status (Feeding America, 2022; Sun et al.,

2016). Sun et al. (2016) suggested that it was imperative for social services to be trauma-

informed due to the link between trauma and hunger.

Legal Assistance. Legal assistance helps clients to secure protective orders from

a perpetrator, child support, child custody, and legal representation (Bennet et al., 2004;

Bouffard et al., 2016; Family Sunshine Center, n.d.). Although victim services are not

just for women, women have utilized these services more than men and they reported

fewer depressive symptoms when they have benefitted from such services (Bennett et al.,

2004). However, Edmond et al. (2013) noted that many individuals are not aware of the

services available to them.

Legal services may be offered by legal agencies, bar associations, victim services

programs, or law schools at free or low costs (Bouffard et al., 2016). In cases of divorce

from a perpetrator, the courts help to protect children and parents by establishing contact

and parenting guidelines (Bouffard et al., 2016; Hartley et al., 2013). Legal services can

intervene on a victim’s behalf if they are experiencing homelessness or housing

instability due to victimization (Bouffard et al., 2016; Hartley et al., 2013).

Legal aid may provide the victim with tenant rights and housing procedures,

assistance in wrongful termination of employment due to absenteeism, and assistance

obtaining unemployment and financial assistance (Bouffard et al., 2016; Hartley et al.,

2013). Hartley et al. (2013) argue that case managers can aid their clients by having

trained knowledge in civil legal issues so that they are able to see the victim’s issues from

a legal perspective and refer them for legal representation. Through the legal lens, one is
 58
able to understand why legal assistance is important to victims of trauma and how legal

assistance can further assist an individual in securing the aforementioned assistance.

TIPP

TIP considers the effects of trauma and the role that it plays in shaping human

growth and development (Ezell et al., 2018). It is the utilization of relational,

organizational, and trauma theory related to the strategies and interventions used in

treatment and service delivery (Bent-Goodley, 2019; Shier & Turpin, 2017). Trauma-

informed policies are system level policies that sets the tone and mission of the

organization so that practices align with an organization’s mission (SAMHSA, 2014).

These policies ultimately create the culture and environment of the organization and its

employees (SAMHSA, 2014).

The purpose of TIPP is to consider the multiple facets of trauma and how they

relate to the individual so that one does not retraumatize the individual (SAMHSA,

2014). The prevalence of trauma, adverse effects, and the cost of trauma has encouraged

human service organizations to address trauma by creating trauma-informed programs

(Classen & Clark, 2017; Lang et al., 2016). However, researchers have realized that TIP

alone do not boost positive outcomes (Chaffouleas et al., 2016; Maynard et al., 2019).

The context in how trauma is addressed and carried out at the organizational level is as

much a part of the equation (SAMHSA, 2014).

Components of TIPP

The shift towards TIC began between the 1990s and early 2000s (Classen &

Clark, 2017). TIC is a standard of care for anyone working with individuals who have
 59
encountered trauma including mental health and healthcare providers as well as teachers,

lawyers, human resource personnel, criminal justice staff, case workers, shelter staff,

nursing home staff, front desk personnel, administrative staff, and housekeeping staff as

well (Bent-Goodley, 2019; Classen & Clark, 2017; Elliot et al., 2005). The terms trauma-

informed care and trauma-informed practice are interchangeable and involve

incorporating:

1. realization of the prevalence of trauma and the effects of trauma;

2. recognition of signs and symptoms of trauma;

3. a comprehensive and integrative response to trauma by individuals, programs,

and systems; and

4. preventing retraumatization (Bryson et al., 2017; Classen & Clark, 2017;

Portman-Thompson, 2020; Purtle & Lewis, 2017; Sullivan et al., 2018; Tebes

et al., 2019).

Realization of the Prevalence of Trauma/Effects of Trauma. Trauma is a well-

documented problem (Baetz et al., 2021; Bryson et al., 2017; Isobel & Edwards, 2017;

Jankowski et al., 2019; Leitch, 2017; Orapallo et al., 2021; SAMHSA, 2014). It occurs

over the lifespan but can begin in childhood (Wolf et al., 2013). Becoming trauma-

informed requires that one recognizes that trauma exists and the negative effects of such

trauma across time and that it often cannot be resolved in a short period of time

(Bargeman et al., 2021; Butler et al., 2011; Wolf et al., 2013). TIP is being considerate of

the staff in the care setting as well as the client (Isobel & Edwards, 2017; Leitch, 2017).

The failure to recognize trauma history and the effects of that trauma can slow client’s
 60
progress or reduce the overall effectiveness of treatment (Butler et al., 2011; Isobel &

Edwards, 2017).

Recognition of Signs and Symptoms of Trauma. Trauma-informed

organizations understand the complexities of trauma, triggers, and vulnerabilities of

clients (Wilson et al., 2013). By doing so, organizations can design trauma specific

services to treat the client’s current trauma symptoms (Bargeman et al., 2021). They may

also be able to guide clients to other necessary services and appropriately interact with

clients (Bargeman et al., 2021; Wilson et al., 2013). It is common for victims to respond

with intense emotions and reactions to trauma (CDC, n.d.). Therefore, interactions with

clients should include listening and encouraging clients to talk about their reactions when

they are ready so that their feelings are validated (CDC, n.d.) Human service

organizations can build trust by removing or reducing punitive action toward trauma

triggered behaviors (Bargeman et al., 2021).

Comprehensive and Integrative Response. Organizations work to properly train

staff and incorporate this knowledge into their organizational cultures, practices, and

policies (Bargeman et al., 2021). Additionally, a comprehensive and integrative response

involves working with clients to tailor a treatment plan specific to the client’s needs and a

sharing of power (Butler et al., 2011; Wilson et al., 2013). Shared power is equalizing

power differentials by combining the knowledge and expertise of the clinician with the

lived experience of the client (National Child Traumatic Stress Network [NCTSN],

2016). This approach recognizes that healing takes place within relationships (Wilson et

al., 2013). Since trauma causes a disruption in healthy relationships, it is important for
 61
clinicians to build an alliance with the client to foster resilience and psychological safety

(Bath, 2015).

Prevention of Retraumatization. Organizations that understand the prevalence

and effects of trauma, recognize the signs and symptoms, and provide comprehensive and

integrative services are more effective in preventing retraumatization (Isobel & Edwards,

2017; Leitch, 2017; SAMHSA, 2014). Prevention of retraumatization is best achieved

when organizations can meet all six principles of TIP (safety; trustworthiness and

transparency; peer support; collaboration and mutuality; empowerment, voice, and

choice; and acknowledgement of cultural, historical, and gender differences and issues)

(CDC, 2023; Isobel & Edwards, 2017; SAMHSA, 2014). I provided more detail

regarding these six principles in the next section.

Trauma-Informed Practice/Program Principles

Incorporating the following six principles is important for developing a trauma-

informed practice and/or program: (a) safety; (b) trustworthiness and transparency; (c)

peer support; (d) collaboration and mutuality; (e) empowerment, voice, and choice; and

(f) acknowledgement of cultural, historical, and gender differences and issues (CDC,

2023; SAMHSA, 2014).

Safety. Psychological and physical safety of clients and staff is important in

trauma-informed practices/programs (Sullivan et al., 2018; Wolf et al., 2013). Safety can

be achieved by creating a welcoming space to promote healthy relationships between

clients and human services providers (Levenson, 2017; Wolfe et al., 2013). Securing the

property so that only those who are working at the organization or receiving services
 62
have access provides an extra safety measure (Levenson, 2017). Examples include things

like having the organization in a safe neighborhood, providing locked doors and limited

access, and having security onsite.

Trustworthiness and Transparency. Organizational practices and decisions

should be made with transparency to provide individuals and families a sense of trust.

Transparency is open and honest decision making and disclosure that increases

accountability and it acts as a value to incorporate in policies and evaluate policies (Ball,

2009). When service providers are open with clients, it conveys a sense of transparency,

and the client does not have to anticipate uncertainty (Levenson, 2017). This exchange

between the client and service provider will promote client autonomy and genuineness

(Levenson, 2017).

Trust can be formed over time by fostering safety and ensuring transparency

(Levenson, 2017). For example, when a therapist establishes a safe environment during

sessions (physical safety and emotional safety), clients may develop trust and will

disclose information that they may otherwise had not shared with individuals whom they

have no trust (Collin-Vezina et al., 2020). Trust can take time to develop and, if the trust

is broken and/or retraumatizing occurs, it can be easily destroyed (Manitoba Trauma

Information & Education Centre, 2013).

Peer Support. Peer support is when individuals form relationships with those

whom they believe can understand what they went through (the other person has

experienced trauma as well) (Charuvastra & Cloitre, 2008; Collin-Vezina et al., 2020).

Having support from peers that have experienced similar traumas can foster trust through
 63
stable, reliable interpersonal connections that can help clients regulate their emotions

(Charuvastra & Cloitre, 2008). It also gives them a sense of hope when they see others

who have been through similar trauma “getting better” and having good things happen in

their lives.

Collaboration and Mutuality. Collaboration and mutuality are achieved through

the acts of valuing the relationship between the clinician and the client and honoring the

client’s experiences (Pemberton & Loeb, 2020). Collaboration and mutuality are goals

for the relationships shared by clients with other clients and organization staff (Collin-

Vezina et al., 2020). It infers that the client is the expert in their own life, which ensures

that the client is able to maintain autonomy over their treatment (Butler et al., 2011;

Wolfe et al., 2014). When clients are receiving services, clinicians make sure that the

clients feel heard and they allow the client to take the lead with professional guidance

(Butler et al., 2011). Clinicians also encourage self-expression, assertiveness, and a space

to challenge belief systems, discussions, and experiences (Pemberton & Loeb, 2020).

Empowerment, Voice, and Choice. Empowerment, voice, and choice help to

promote resilience for trauma recovery and self-advocacy (Kusmaul et al., 2015; Wilson

et al., 2013; Wolf et al., 2014). Empowerment is a state of being empowered to do

something: power, right, or authority to do something (Merriam-Webster, 2022). In

terms of trauma, empowerment, voice, and choice builds upon the client’s strengths and

experiences to teach self-advocacy and assist in shared decision making, choice, and goal

setting (Page & Czuba, 1999; SAMHSA, 2014).

The concept can employ clients to take control of their lives which also helps
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clients to maintain autonomy in treatment because it focuses on the client’s strengths

(Bargeman et al., 2021; Collin-Vezina et al., 2020). Victims often feel powerless after

they have been victimized (Fallot & Harris, 2002). It is important that clinicians

recognize the power differential between themselves and their clients to not recreate the

feeling of loss of control and help their clients use their power in relationships

(Pemberton & Loeb, 2020).

Acknowledgement of Cultural, Historical, and Gender Differences/Issues.

Cultural, historical, and gender concepts consider stereotypes and biases and how these

can lead to retraumatization (Butler et al., 2011; SAMHSA, 2014). These stereotypes and

biases are based on gender, race, religion, sexual orientation, age, geography, and

ethnicity (SAMHSA, 2014). Trauma-informed organizations seek to provide unbiased

services that are diverse and culturally competent (Pemberton & Loeb, 2020; SAMHSA,

2014).

Organizations that effectively incorporate these concepts create policies and

practices that promote the healing of historical trauma and they incorporate the racial,

ethnic, and cultural needs of the people they serve (SAMHSA, 2014). Policies rooted in

social inequities can be further traumatizing for clients. Populations such as the elderly,

children, veterans, religious, ethnic minorities, and the LGBTQ have vulnerabilities that

require special attention to their needs (Butler et al., 2011). The stressors related to being

a member of these groups should be considered when creating policies at the

organizational level (Butler et al., 2011).

Culture/History. Cultural considerations acknowledge the victims’ cultural

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values, beliefs, and practices (Children’s Hospital of Philadelphia, 2021). Historical

trauma is the multigenerational, collective experience of psychological and emotional

injury of communities and in descendants (SAMHSA, 2014). Ethnic minorities, legal

immigrants, and undocumented individuals may feel rejected due to social and political

climates that perpetuate rejection of these individuals (Pemberton & Loeb, 2020).

Immigrants also face stigmas surrounding mental health (Butler et al., 2011). Histories of

violence and human rights abuses create fear (Butler et al., 2011). Native Americans were

victims of violent colonization that affected traditional ways of childrearing, family

structure, and relationships and disrupted the sense of community within the tribe

(SAMHSA, 2014; Stamm et al., 2004). This then leads to the discussion of the cultural

concepts of trauma.

Since trauma is subjective, cultural beliefs can have an impact on the meaning

that victims make of their trauma (Children’s Hospital of Philadelphia, 2021). Some

cultures may view trauma as a punishment or a rite of passage (Children’s Hospital of

Philadelphia, 2021). Stamm et al. (2004) also pointed out that cultural concepts of trauma

can be in the past or currently happening. Cultural trauma can include denying a group to

engage in religious practices or access to public spaces (Stamm et al., 2004).

Gender/Sexuality. Gender differences and issues reflect the trauma experienced

due to sexism and it acknowledges the differences in how males and females experience

trauma as well as the different rates at which that trauma is experienced (Epstein &

Gonzalez, n.d.; NCCD Center for Girls and Young Women, 2010). Viewing trauma

through a gender lens highlights the role of gender in the rate of trauma experienced and
 66
how it is experienced (Epstein & Gonzalez, n. d.; NCCD Center for Girls and Young

Women, 2010.). For example, males do not report sexual abuse, sexual assault, physical

punishment, or psychological distress as often as girls (NCCD Center for Girls and

Young Women, 2010). However, males are more likely to experience non-sexual

assaults, accidents, illness, injuries, and witness to death or injury (NCCD Center for

Girls and Young Women, 2010). This also applies to gender identity and sexuality.

Individuals who are LGBTQ report trauma at a higher rate than other groups (Epstein &

Gonzalez, n.d.). Social climate again can play a role in how we see trauma perpetuated

against females and the LGBTQ community (Pemberton & Loeb, 2020).

TIPP Implementation and Effectiveness in Human Service Organizations

TIPP in human service organizations begins with changing the organizational

culture, implementing agency policies, and then providing training to all staff (Bargeman

et al., 2021; Menschner & Maul, 2016). Implementing TIPP at the organizational level

includes six key concepts: (a) leading and communicating about the transformation

process; (b) engaging clients in organizational planning; (c) training clinical and non-

clinical staff; (d) creating a safe environment; (e) preventing vicarious trauma in staff;

and (f) hiring a trauma-informed workforce (Menschner & Maul, 2016). Experts

recommend that these organizational changes take place before implementing TIP

(Menschner & Maul, 2016).

Leading and Communicating Transformation. Leading and communicating

about the transformation process requires that leadership support their staff. This also

involves communicating why these changes are necessary so that they promote buy-in
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from the staff (Menschner & Maul, 2016). Conversations on how to become trauma-

informed are needed within different levels of the organization and, without it, change

will not last (Bloom, 2017; Bloom & Sreedhar, 2008).

Policy and practice should support staff and the clients that they serve (Bowen &

Irish, 2020; Bryson et al., 2017). Human service providers advocate for communities

ridden with violence, substance use, and child maltreatment (Kawan & Martinez, 2016).

Advocating sometimes includes working with legislators and fighting for coverage of

trauma treatment (Kawan & Martinez 2016). Researchers have found it to be rare, or

almost non-existent, for policies to reflect all six trauma principles (Bowen & Irish,

2020). Policy mapping could be a solution to better implementing policy changes and

ensure that all six trauma principles are in existence throughout the organization (Bowen

& Irish, 2020).

The effectiveness of TIPP is dependent upon the prioritization of TIC by

leadership staff that supports advanced training, listening, program evaluation for

improvements, and aligning policy and practice with principles of TIP (Bryson et al.,

2017). Evaluation is the understanding of the effectiveness of practice and improvement

(Herbert, 2015). It ensures that there is accountability for program outcomes and it

legitimizes marginalized perspectives (Herbert, 2015). Policies and procedures are the

core of a trauma-informed organization and should consist of TIP in admissions,

screening and assessment processes, informed consent, treatment planning, referrals,

confidentiality, discharge, and other services (SAMHSA, 2014). Client needs are

consistently changing and new science emerges (SAMHSA, 2014). Therefore, program
 68
evaluation must occur regularly and policies and services should be updated to prevent

retraumatization (SAMHSA, 2014).

Engaging Clients in Organizational Planning. A stakeholder committee should

be utilized to engage clients in organizational planning because individuals who

experienced trauma firsthand are able to provide valuable information (Menschner &

Maul, 2016). Sullivan et al. (2018) highlighted evidence that supports the effectiveness of

empowerment practices in restoring personal, interpersonal, and social power to domestic

violence victims. Empowerment practices provide victims with community resources,

support and respect, safety planning, and rights and options (Sullivan et al., 2018).

Empowerment practices helped domestic violence victims to have decreased depressive

symptoms and increased self-efficacy mainly due to trained staff providing

psychoeducation about trauma, normalizing trauma, and identifying new ways to cope

(Sullivan et al., 2018). By involving clients in the planning process to reduce

retraumatization, they are able to be empowered and give feedback to the organization

about how well it is doing and/or what improvements need to be made.

Training Clinical and Nonclinical Staff. Training is necessary for clinical as

well as non-clinical staff in relation to the implementation of TIPP (Bargeman et al.,

2021; Menschner & Maul, 2016). The training should include an explanation of the

reorganization, changes in policies/procedures, the reasoning behind the changes, detailed

information about the signs and symptoms of trauma, and specific training about

avoiding retraumatization through their actions as they support clients (Bargeman et al.,

2021). Provider trauma training and trauma training for front line staff enhances the
 69
effectiveness of TIPP implementation (Baetz et al., 2021; Von Dohlen et al., 2019).

When mental health practitioners are trained properly, they are less inclined to use

labels and less rigid in their approaches with clients. They have also been found to listen

more and pay more attention to client needs (Dublin et al., 2021). Repeated and direct

confrontation with adaptive challenges is important to TIPP effectiveness as well as staff

training other staff because they both promote positive changes in knowledge, beliefs,

and behaviors (Bryson et al., 2017; Jankowski et al., 2019; Orapallo et al., 2021).

Creating a Safe Environment. Safety is another component important to the

implementation of TIPP. As previously discussed, emotional and psychological safety is

important when treating victims who have been traumatized (Sullivan et al., 2018; Wolf

et al., 2013). Having consistent organizational policies on how reports of abuse will be

addressed, de-escalation strategies, and keeping victims informed of rules, procedures,

and expectations are important elements of providing safety through consistency (Butler

et al., 2011).

Preventing Vicarious Trauma in Staff. Secondary stress is trauma symptoms

exhibited as a result of repeated exposure to the experiences and trauma stories of victims

(Wolf et al., 2014). Secondary stress experience by staff can be prevented by providing

staff with support and supervision (Wolf et al., 2014). Organizations with cultures more

supportive of trauma-informed employees are more effective in implementing TIPP

changes in the organization (Dublin et al., 2021).

Hiring Trauma-informed Workforce. The allocation of resources and funding

are also important to the effectiveness of TIPP (Bryson et al., 2017; Dublin et al., 2021).
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When more resources are allocated on the front-end, larger scale organizational changes

can produce longer and deeper changes to organizational culture (Bryson et al., 2017;

Dublin et al., 2021). Hiring trauma-informed staff is necessary in continuing to

implement the other five key concepts and the importance of properly trained staff,

including identifying secondary stress in themselves, continues to be reiterated

throughout the literature (Baetz et al., 2021; Butler et al., 2011; Dublin et al., 2021;

Menschner & Maul, 2016; Von Dohlen et al., 2019; Wolf et al., 2014).

Summary and Conclusions

The cost of trauma in the U. S. is $671 billion a year (CNTR, 2020). Public

systems have begun implementing TIPP due to the increased potential that individuals

will be traumatized through practices and policies (Loomis, 2018). However, the

practices and policies may not be consistent across organizations and services (Carello &

Butler, 2015; Hanson & Lang, 2016). Therefore, the research study outlined in Chapter 2

was used to understand case managers’ perceptions on TIPP in human service

organizations. Case managers’ beliefs and attitudes about the practices and policies of

their organization helped to inform human service agencies on best practices, policy, and

training needs (Bryson et al., 2017; Ezell et al., 2018).

An individual’s environment helps to shape their psychological development

including attitudes and behaviors (Lewin, 1946; Piaget, 1976). Bronfenbrenner (1979)

described the environmental context of behavior through five interrelated systems (micro-

, meso-, exo-, macro-, and chronosystem). Trauma can be experienced within, or across,

any system that an individual functions within (DeCandia & Guarino, 2015). Thus, the
 71
interactions that individuals have with/within their environment is a characterization of

how individuals experience events in their life (Zhu et al., 2020). Therefore, it is

understood that individuals can be retraumatized by another traumatic or stressful event

experienced within any level of ecological systems (Gibson, 2008).

Researchers have indicated that TIPP is instrumental in reducing trauma

symptoms (Baetz et al., 2021). Researchers have also shown that staff trauma training is

instrumental in promoting organizational safety climate and morale, managerial staff

support, teamwork climate and collaboration, and staff compassion satisfaction (Dublin et

al., 2021). Furthermore, staff training other staff promoted increased knowledge, positive

beliefs, and positive behaviors (Bryson et al., 2017; Jankowski et al., 2019; Orapallo et

al., 2021). On the contrary, there is no definitive or universal definition on what TIPP is

and how to train students and practitioners in trauma competencies (Baetz et al., 2022;

Sullivan et al., 2018). This research helped to identify the relevancy/need for TIPP as it

relates to case managers in human services. It also add ed knowledge to the body of

literature that already exists.

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Chapter 3: Research Method

The purpose of this generic qualitative research study was to describe and

understand case managers’ perceptions of TIPP across organizations and services.

Researchers have highlighted implementation efforts on TIPP, but describing case

managers’ beliefs and attitudes about the practices and policies of their organization may

help to inform human service agencies on best practices, policy, and training needs

(Bryson et al., 2017; Ezell et al., 2018). Further research was warranted on case

managers’ perceptions on TIC, TIP, and trauma-informed policies within their

organizations to address the negative repercussions of retraumatization experienced at the

hands of organizations and systems meant to help victims of traumatic events. In Chapter

3, I discuss research design and rationale, role of the researcher, and the methodology. I

also discuss issues of trustworthiness and ethical procedures.

Research Design and Rationale

The research question guiding this study was “What are case managers’

perceptions of TIPP in human service organizations?” A generic qualitative research

methodology was determined to be the best fit for this study. Generic qualitative research

is appropriate when used to understand an individual’s perceptions about their

experiences (Jahja et al., 2021; Percy et al., 2015). Generic qualitative research is

flexible, can be applied to existing theories, and provides a background for exploring

research questions not suitable for traditional qualitative methodologies (Harris &

Phillips, n.d.). The weaknesses of generic qualitative research are lack of theoretical

backing, minimal literature defining the approach, and mixing elements of various other
 73
methodologies, which may cause confusion among elements of the research (Harris &

Phillips, n.d.). However, because generic qualitative research does not conform to the

constraints of other methodologies yet combines elements of other qualitative

methodologies, this allows more flexibility with the design of their research, data

collection, and analyses (Jahja et al., 2021; Kahlke, 2014; Percy et al., 2015). This

qualitative research design was used to collect, code, and analyze data to describe the

perceptions and experiences of case managers in human service organizations related to

TIPP. It was the most appropriate of the research designs for my study as it does not have

the limitations of the other qualitative designs.

A phenomenological research design was considered because it is used to

understand the lived experiences of individuals and the meaning individuals make of

those experiences (Alase, 2017). But a phenomenological study was not appropriate

because its data collection process and analysis is more structured than the general

qualitative approach and it requires that the interviewer has a true and deeper

understanding of the participants’ experiences (Alase, 2017). The most notable element

of phenomenological research is that it is used to understand affective, emotional, and

intense human experiences (lived experiences) and not the subjective perceptions of

participants (Emiliussen et al., 2021; Worthington, 2013). A case study design was also

not appropriate because it is more focused on an individual or multiple individuals over a

period of time (Creswell et al., 2007; Ebneyamini et al., 2018). Due to the research

question posed in this study, it did not require participants to be studied over a longer

period of time.
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Role of the Researcher

As the researcher, my role was that of an observer-participant (Austin & Sutton,

2015). Observer-participants identify themselves as researchers and interact with the

participants but do not claim to be an actual participant (Orellano & Fang, n.d.). My role

as the observer-participant was fulfilled by conducting semistructured interviews with the

research participants. I was the primary instrument for data collection and analysis. I

collected, analyzed, and interpreted the data using the procedures outlined throughout

Chapter 3.

To avoid unintentional coercion to participate and/or issues with working or

personal relationships, I did not recruit or collect data from individuals with whom I have

previous work or personal relationships. I also wanted to ensure that I avoided researcher

biases than can be more apt to exist when the researcher has another relationship with the

participant outside of the research study (Chenail, 2011). The participants were presented

with an explanation of the goal of the researcher and I did my best to remain unbiased

and neutral during the data collection, analysis, and interpretation process (Bell-Martin,

2019; Sauro, 2015). Other researcher biases can include prior knowledge of the

population being studied, confirmation bias, question-order bias, and leading questions

and wording bias (Chenail, 2011; Shah, 2019). Confirmation bias is interpreting data to

support the hypothesis or omitting data that does not favor the hypothesis (Shah, 2019).

Question-order bias occurs when participants’ responses to subsequent questions are

influenced by prior questions (Shah, 2019). Leading questions and wording bias prompts

participants’ responses in the direction of favorable outcomes (Shah, 2019).

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I managed researcher bias through bracketing. Bracketing is a process of self-

awareness that allows the researcher to be conscious of their biases, past experiences, and

emotional reactions (Baksh, 2018; Starks & Trinidad, 2007; Tufford & Newman, 2010).

One way to carryout bracketing is to keep detailed notes of my experiences and

responses, thoughts, and preconceptions throughout the study (Dörfler & Stierand, 2020;

Starks & Trinidad, 2007; Tufford & Newman, 2010; Weatherford & Maitra, 2019). This

can be done by keeping a reflexive journal (Patnaik, 2013; Weatherford & Maitra, 2019).

The reflexive journal can be used before, during, and immediately after the interview to

document attitudes likely to influence data and observations, thoughts, and interpretat ions

following the interview (Patnaik, 2013). When one is aware of their preconceptions, they

are able to be more objective so that they do not allow their assumptions to influence data

collection and analysis (Döfler & Stierand, 2020; Tufford & Newman, 2010). Finally, I

consulted with colleagues and mentors throughout the data analysis process while making

note of how my thoughts and ideas evolved and changed (Johnson et al., 2020; Starks &

Trinidad, 2007). Utilizing notes or memos can serve as a paper trail to track emerging

ideas or impressions of what the data means, how they relate to one another, and how my

understanding is shaped by the data (Maher et al., 2018; Starks & Trinidad, 2007).

Methodology

Participation Selection Logic

Population

For this study, I recruited human services case managers who have had training in

TIP and/or policy. Human services professionals are social service professionals that
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provide an array of services to individuals who may be in need of housing and food

(Chron Contributor, 2021). Human services professionals may also work with victims

and individuals with disabilities (Chron Contributor, 2021). Human services

professionals are employed in nonprofit organizations, for-profit social service

companies, and government agencies (U.S. Bureau of Labor Statistics, 2022). Human

services professionals can include health education specialists, community health

workers, counselors, correctional treatment specialists, probation officers, school and

career counselors and advisors, social and human service assistants, and social workers

(U.S. Bureau of Labor Statistics, 2022). According to the U.S. Bureau of Labor Statistics

(2022), community and social service occupations are expected to grow by 12%, adding

346,900 jobs in the next 10 years.

Sampling Strategy

Participants were recruited using a combination of purposive and snowball

sampling. Purposive sampling allows access to individuals with the experience and/or

knowledge that the researcher is attempting to gather (Campbell, 2020; Suri, 2011).

Snowball sampling was also used to allow for those who have participated (or saw the

recruitment materials) to tell others who may be interested or meet the criteria for

participation (Naderifar et al., 2017).

Sample Size and Saturation

Saturation is important to reach in qualitative research (Boddy, 2016; Guest et al.,

2020; Malterud et al., 2016; Mason 2010). Saturation is reached when new information

does not shed any new light on the phenomenon or issue being studied (Hennink &
 77
Kaiser, 2022; Mason, 2010). Researchers have indicated that saturation in qualitative

research can be reached with as few as eight participants or it may take many more

depending on the topic (Boddy, 2016; Dworkin, 2012; Guest et al., 2020; Mason, 2010).

Therefore, I planned to recruit and interview a minimum of eight participants, and I

expected to reach saturation by 15 participants. I shared information with my chair and

committee as I went through the data collection and analysis process to determine when I

had reached saturation and could stop data collection.

Inclusion/Exclusion Criteria

In order to be included in the study, a potential participant must have met all the

following criteria:

• Be18 years of age or older;

• Be a case manager or equivalent position managing the cases of

individuals and/or families;

• Currently, or in the past, have worked in a human service organization that

has trauma-informed practices and policies in place;

• Read and understand English.

Any individuals who did not meet all the inclusion criteria were excluded from the study.

Recruitment

I posted recruitment materials (see Appendix A) on social media sites as well as

the Walden University Participant Pool. I attempted to use social media sites that did not

require permission of a moderator or organization to post. However, I sought permission

beforehand from those social media sites that required permission.

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The potential participants reached out to me via email or phone. I then asked them

the following inclusion questions:

1. Are you at least 18 years of age?

2. Are you a case manager (or equivalent position where you manage the cases

of individuals and/or families)?

3. Do you currently, or in the past, have worked in a human service organization

that has trauma-informed practices and policies in place?

4. Do you read and understand English?

If on the phone, if they answered all of the question “yes”, I asked them for an email

address where I sent them the informed consent form as well as a list of possible dates

and times to set up their interview. For those who contacted me via email, I emailed

them the list of inclusion questions and asked them to respond with answers to each.

For those that answered “yes” to all of the inclusion items via phone or email, I

then emailed a copy of the informed consent form as well as a list of dates/times available

for the interview. I asked them to review the informed consent carefully and respond to

the email with the words “I consent to participate” if they consented to participate as well

as included the dates/times that work for them for the interview. Once I received an

email with these things included, I responded with a final interview appointment as well

as a Zoom link for their interview appointment.

Instrumentation

Demographics

Demographic items were collected in order to provide a description of the study

 79
sample (see Table 1, Appendix B). All data were reported in aggregate to ensure that

individuals could not be identified.

Table 1

Demographic Questions

# Question Prompt(s)
1 What is your gender? Male, female, other, prefer not to answer
2 What is your age? Actual age in years
3 What is your race/ethnicity? White, Black or African American, American
Indian or Alaska Native, Asian, Native
Hawaiian or other Pacific Islander
4 What is your highest level of education? No high school diploma, HS diploma/GED,
Certificate, Associates degree, Bachelor’s
degree, Master’s degree, Doctorate degree
5 How long have you been a case manager? Actual number of years
6 Have you undergone trauma -informed Yes, no, not sure
practice training at any time?
7 What type of human service organization do Government, Non-Profit, Private
you/did you work for that had trauma -
informed practices/procedures?

Interview

Semistructured interviews were used to gather data from the participants. See

Table 2 for the interview questions and prompts.

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Table 2

Semistructured Interview Questions & Prompts

# Question Prompts
1 Describe the trauma -informed policies at your organization. Tell me more about those policies
such as their purposes in the
organization.
2 How did you implement these practices? Give me more information about
what you did.
3 What trauma -informed practices were implemented or Tell me more about how those
changed at your organization over time? changes took place.
4 How were you told to implement those changes? Tell me more about how you carried
out those changes.
5 What is the protocol for handling trauma victims or crisis Is this typically how they are
situations at your organization? handled? Why or why not?
6 What types of victims do you feel prepared to work with Give me more detail on your
due to the trauma -informed practices at your organization? reasoning.
7 How well did your supervisors support you in your Tell me more about what your
implementation of trauma -informed practices? supervisors did to support you.
8 What changes, if any, do you feel need to be made in Tell me more about those changes.
trauma -informed practices (as they are implemented) to
better help victims?
9 Are you aware of any other trauma -informed practices Tell me more about what they are
and/or policies that would benefit your organization? and how they would benefit your
organization.
10 Please share any additional information you think is
important to our topic of discussion that I may not have
asked.

Procedures for Recruitment, Participation, and Data Collection

Participation

Upon meeting with the participant for the interview, I reviewed informed consent

and confidentiality with the participant. The participant was notified of their right to

withdraw from the study at any time with no penalty to them. I then asked the participant

if I could start the recording. If they said “no”, I would thank them for their time and

ended the interview. If they said “yes”, I moved on to the demographic questions and

then the interview questions (see Appendix B).

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Data Collection

Interviews were conducted via Zoom. I recorded the audio part of the interview.

Participants had the choice to be on video or not but, if they chose to be on video, I did

not record the video portion of the interview. Throughout the interview I made

handwritten notes of the participants’ responses. My notes reflected the responses that

may have needed to be probed, clarification needed on a response, or notes of

observations noted in the participants’ responses.

After the interview questions had been completed, I stopped the audio recording

and thanked the participant for their participation. I let the interviewee know that I would

have the recordings transcribed and I would email them a copy of the transcript for them

to check for accuracy. I let them know that if they d id not respond to this email within

seven days, I would assume that the transcript was accurate and move on to data analysis.

I also let them know that after my final project was approved by the university I would

share the overall results by posting a summary at this webpage:

[Link] I asked if they had any additional

questions, thanked them again for their participation, and ended the interview.

Interviews were transcribed by using Rev ([Link]). Once the interviews

were transcribed, I listened to the audio recordings to check them for accuracy and made

note of any corrections and then emailed the transcript for review. If the participant did

not respond, then I proceeded with data analysis.

Data Analysis Plan

I used thematic analysis to analyze the data which allows the researcher to
 82
identify common themes that repeatedly show up in the data (Nowell et al., 2017).

Thematic analysis was completed utilizing the following steps for each participants’ data

(Saldana, 2013).

In Step 1 I familiarized myself with the data by reviewing the participants’

transcripts. I then started utilizing generic coding methods to determine which method

was best suited for my study. Saldana (2013) recommended starting with a combination

of attribute coding, structural coding or holistic coding, descriptive coding, and In Vivo,

initial coding, and/or values coding to determine which method yields substantive codes.

For Step 2, eclectic coding was used to transition into second cycle coding. Eclectic

coding allowed the data to be recoded based upon what was learned from the first coding

cycle.

In Step 3, after the first cycle coding, code mapping was used to reorganize,

recategorize, and conceptualize the codes (Saldana, 2013). It can be utilized

simultaneously with second cycle coding (Saldana, 2013). I also used code landscaping

which can be done through an internet tool called Wordle ([Link]). Code

landscaping identified frequent words or phrases for potential codes and categories. In

Step 4, I transformed the final set of codes and themes into longer phrased themes to

theme the data.

For Step 5 I may have needed to transition to second cycle coding depending

upon the chosen method of first cycle coding (Saldana, 2013). If second cycle coding was

needed, I used a second cycle coding method to reorganize the data into higher-level

categories and themes (pattern coding, focused coding, axial coding, theoretical coding,
 83
elaborative coding, or longitudinal coding). In Step 6 I created a top ten list and then

narrowed it down to the main three codes, categories, or themes to determine how they

relate to one another. In Step 7, I used codeweaving to integrate key code words and

phrases in narrative form to identify how they relate to one another. I then applied the

touch test to determine how codes and categories could be reworded and transformed into

more abstract meanings. Finally, in Step 8 I wrote a final report on my findings.

Issues of Trustworthiness

Trustworthiness in qualitative research refers to the degree of confidence

interpretation and the methods used to ensure the quality of a study (Connelly, 2016;

Stahl & King, 2020). It is most often measured using the criteria of credibility,

dependability, transferability, and confirmability of the study (Gunawan, 2015; Stahl &

King, 2020). Meeting the criteria of credibility, dependability, transferability, and

confirmability means that one has taken the necessary steps to safeguard against bias and

ensure rigor (Gunawan, 2015).

Credibility

Credibility in qualitative studies corresponds to internal validity in quantitative

research (Gunawan, 2015; Stahl & King, 2020). Researchers should use prolonged

engagement with participants, persistent observation, peer-debriefing, member checking,

and reflective journaling to ensure credibility (Connelly, 2016; Stahl & King, 2020). I

used member checking and reflective journaling to ensure credibility during the data

analysis process.

A copy of the interview transcript was emailed to the participants after I checked
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it for accuracy. The participants had the opportunity to check the interview for accuracy

and to make any clarifications if needed. The member checking process allowed

participants to give an accurate portrayal of their experiences through this process to add

credibility to the research study (Candela, 2019).

I also used reflective journaling. Reflective journaling involves keeping detailed

notes of my experiences and responses, thoughts, and preconceptions as they unfold

throughout the study making for a more objective data analysis process (Johnson et al.,

2020; Starks & Trinidad, 2007; Tufford & Newman, 2010). Through reflexive journaling,

I recorded my previous knowledge of trauma and/or TIPP gained through my current

work in a clinical trauma setting, any thoughts or interpretations that may have a bearing

on the data analysis process, and immediate observations from the interviews (Johnson et

al., 2020; Patnaik, 2013).

Transferability

Transferability is the generalizability of the results of the study to others outside

the sample (Connelly, 2016; Stahl & King, 2020). The findings of the study should have

meaning outside of the immediate context of the study (Finfgeld -Connett, 2009; Stahl &

King, 2020). I met the criteria of transferability by collecting participant demographics

(Appendix B) and reporting those demographics in aggregate (Chowdhury, 2015). I

provided a comparison to the population of human service workers so that it could be

determined if my sample was in line with the demographics of the larger population.

I also met the criterion of transferability through data saturation. Data saturation is

used to describe rich, descriptive data that is repetitive which can be assumed to be the
 85
same or similar across the population studied (Guest et al., 2020; Hammarberg et al.,

2016; Hennink & Kaiser, 2020). I worked with my committee members to determine

when I had reached saturation in my data.

Dependability

Dependability in qualitative studies commonly equates to reliability in

quantitative research (Connelly, 2016; Stahl & King, 2020). I ensured dependability of

the research by using an audit trail throughout the study that detail my steps so that the

study can be replicated (Anney, 2014; Connelly, 2016; Stahl & King, 2020). The audit

trail included interview audio and transcripts, participant demographics, and researcher

notes (Anney, 2014). Researcher notes included observations from the interview,

thoughts and interpretations about the dialogue between the researcher and participant,

and/or any descriptive accounts of the research (Carcary, 2020; Mulhall, 2002).

Researcher notes helped to provide insight into the process of the study and the research

findings for consistency (Golafshani, 2003; Phillipi & Lauderdale, 2018).

Confirmability

Confirmability refers to the degree to which the research can be replicated by

other researchers (Chung et al., 2020; Anney, 2014). Chapter 3 has been a detailed

discussion of how to replicate this study that other researchers should be able to replicate.

I provided an explanation of the different phases of data coding and theming of the data

in chapter 4. I continued to refer to all records, electronic and written, for reference when

completing the data analysis, results, and interpretation of those results (Anney, 2014).
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Ethical Procedures

Once IRB approval was granted, I recruited participants and collected data

following the process outlined earlier in chapter 3. No incentives were provided to

participants to participate in the study. I did not interview individuals that I had a current

or past professional or personal relationship. No individuals were identified in my study

and I used pseudonyms for each participant as well as each participant’s place of work (if

that information was shared with me as part of the answers to the interview questions).

The only individuals who knew the names of the participants and saw raw data

(recordings, transcripts) were myself, my committee members, the IRB (if requested),

and [Link] which has a confidentiality agreement.

Informed consent was provided to all participants via email once it was

determined that they met the inclusion criteria. Participants were asked to carefully

review the informed consent and responded to the email by typing “I consent” if they

agreed to participate in the interview. The research study posed minimal risks to the

participants. However, the topic of trauma may have been a sensitive subject for

individuals to discuss. Research participants were provided information for the crisis

textline if they needed to talk to someone. The crisis textline is a free service for all

individuals and is available 24 hours a day, 7 days a week. The crisis textline information

was provided in the informed consent form and the information was verbally shared with

the participants at the beginning of the interview. I also provided participants with the

National Suicide Prevention lifeline at 1-800-273-8255 which is available 24 hours a day,

7 days a week through the informed consent form. Participants may also access the
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Suicide and Crisis Lifeline by dialing 988 which was included in the informed consent.

Data collected (interview recordings, transcripts, data codings) was kept on a

flash drive in a password protected file containing only information from the research

study. The flash drive was stored in a locked file cabinet that I only have the access key.

Data is kept for a minimum of five years after CAO approval of the study per Walden

University IRB guidelines (Walden University, 2022). After this period of time, all data

associated with the study will be destroyed.

Summary

The purpose of this generic qualitative research study was to describe and

understand case managers’ perceptions of TIPP across organizations and services. I

provided a detailed description of the research design and rationale and my role as the

researcher. I also discussed the research methodology which included participant

selection logic, instrumentation, and procedures for recruitment, participation, and data

collection. Issues of trustworthiness and ethical procedures were thoroughly discussed.

Chapter 4 included the results of the data collected along with tables or charts

representative of the themes that emerged from the data.

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Chapter 4: Results

The purpose of this generic qualitative research study was to d escribe and

understand case managers’ perceptions of TIPP across organizations and services. I

sought to understand the level of training and education case managers had before

providing services to victims of trauma. I also wanted to understand the policies and

practices implemented in human services organizations. I wanted to know whether case

managers feel the current policies and practices are beneficial to themselves and victims

of trauma. Researchers have highlighted numerous implementation efforts of TIP and

policy but describing case managers’ beliefs and attitudes about the practices and policies

of their organization may help to inform human service agencies on best practices,

policy, and training needs (Bryson et al., 2017; Ezell et al., 2018). The research question

that guided this study was “What are case managers’ perceptions of trauma-informed

practice and policy in human service organizations?” In this chapter I discuss the setting,

demographics of the sample, description of the data collection and coding of data into

themes, and results related to the research question.

Setting

The data collection process began on November 08, 2022, after approval was

granted from Walden University’s IRB. Social media posts were posted on Facebook,

Twitter, and LinkedIn. Recruitment slowed during the Thanksgiving and Christmas

holidays and other avenues for recruitment were considered. However, the number of

individuals contacting me began to increase after the new year and no other recruitment

measures took place. Recruitment ended on May 7, 2023. One participant utilized closed
 89
caption during their interview due to hearing loss. No other participants were impacted by

personal or organizational conditions at the time of the study.

Demographics

The sample for this study included eight participants who were interviewed before

I reached saturation. Only one of the eight participants was male and only one was

Black/African American. Six participants had worked in nonprofit organizations. Five of

the eight participants had a bachelor’s degree (see Table 3).

Table 3

Participant Demographics

# Gender Age Race/Ethnicity Highest Level Years of Employer Type

of Education Experience

P1 Female 51 White Bachelors 10 Non-Profit

P2 Male 28 White Bachelors 5 For-Profit
P3 Female 51 White Masters 10 Non-Profit
P4 Female 42 White Bachelors 19 Non-Profit
P5 Female 29 White Bachelors 3.5 Non-Profit
P6 Female 59 White Masters 7 Non-Profit
P7 Female 28 White Masters 5 Gov’t/Non-Profit
P8 Female 40 Black/African Bachelors 2 Non-Profit
American

Data Collection

I conducted one semistructured interview through Zoom with each participant that

ranged from 30–60 minutes. Participants were asked ten open-ended questions (see

Appendix B) regarding TIP in the human service organizations in which they worked.

After obtaining consent, the interviews were audio recorded using the Zoom platform and

transcribed immediately after using [Link]. Participants were emailed the transcription

and given seven days to make any corrections. One participate made a correction to their

transcript while the other participants made no corrections.

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Data Analysis

Initial Coding

The audio and transcripts were carefully reviewed for accuracy to be sure that I

was able to extract meaning from the data. After carefully reviewing the audio and

transcripts, I utilized in-vivo coding to begin the initial coding process. I highlighted

phrases of information in each interview transcript that were relevant to the interview

question asked. I then took the data and input it into an Excel spreadsheet where

participant responses were grouped according to the questions asked. Once all the data

were grouped relevant to the interview questions, I generated initial codes and created

PowerPoint slides to print so that I would have a tangible copy of the information for

code mapping. Table 4 contains examples of the initial round of coding.

Table 4

Initial Cycle of Coding Examples

Participant Quote Initial Code

P4 Trauma-informed and person-centered or Addressing victims with
victim-centered go together. trauma-informed language
P3 Specialized speakers to work with trauma- Training practices
informed care policies and direct services.
P2 Is this a trauma response? Understanding trauma
behaviors
P3 An annual review of the policies are available to Creating organizational
the public and participants. transparency
P4 We don’t initiate anything that’s going to bring Providing trauma-informed
up any kind of bad feelings or anything like that. care

Second Cycle Coding

In-vivo coding and initial coding served as a catalyst to transition into second

cycle coding. I reviewed each slide and then generated new codes based on the
 91
information gathered. The data were regrouped and categorized. I created a tangible

version of code mapping using additional PowerPoint slides that I printed after using

code landscaping. Table 5 is a display of the transition from the initial coding process

into second cycle coding.

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Table 5

Second Cycle Coding Examples

Participant Quote Initial code Second cycle code
P6 We’re taught to be empathetic listeners. Trauma-informed Importance of diverse trauma-
response informed training practices
You don’t want to be bringing up all that.
P2 Say, okay, what happened to you? Looking at trauma
symptomology
Person presenting bad behavior?

Are they being defiant?

Reactive attachment disorder

Look at their background.

Client’s history

How is that affecting your behavior?

How is that affecting your circumstances and

symptoms?

What trauma looks like and how it presents.

P4 We don’t bring up anything that’s going to initiate Trauma-informed
any bad feelings or anything like that. response

Different reactions and sometimes the parents'

reactions aren’t what you would think.

Trauma-informed and person-centered or victim-

centered go together.
P5 Training on first-person language Addressing victims with
trauma-informed
language
P6 Needs of the participants always come first. Trauma-informed
response
P8 The participant comes first. Trauma-informed
Person served. response
P4 Community collaboration Multiple service needs Community
collaboration/collaboration
P1 Mobile crisis Multiple service needs
P2 Defer to 911 Multiple service needs

Crisis hotline
P3 Law enforcement Multiple service needs

Sexual assault agencies

Collaboration with other agencies

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Participant Quote Initial code Second cycle code
P3 Annual Training duration or Trauma-informed
frequency (time) training practices
Every fiscal year
Training requirements
P2 Specialized speakers to work with trauma-informed care Training duration or
policies and direct services. frequency (time)

Required annual agency training date. Training requirements

Annual retreat.

15 minutes to 2-hour modules.

Digital platform

Minimum of 80%
P7 Quarterly trainings Training duration or
frequency (time)
P5 Quarterly trainings Training duration or
frequency (time)

Training requirements
P6 5 or 6 mandatory trainings Training duration or
frequency (time)
Ongoing
Training requirements
Annual Retreat
P3 An annual review of the policies and available to the public Creating organizational Creating
and participants. transparency organizational
The leadership staff would review policies and then also if transparency
a policy was in question, staff could grieve it.

Then through the grievance policy, our leadership team

would look at it again.

Policies would also be provided on our website.

Discrepancy in implementation, they were available to be

viewed.
P5 Much larger focus on employee wellness. Employee Support/lack of Employee wellness
employee support focus important
Sensitivity to the trauma that their employees were going
through secondhand trauma and burnout and all the
associated negative things with that.

Employee organization that was focused on employee

wellness.

Switched to lowering caseloads.

Making sure employee mental health services were more

readily available.

Switch from having sick leave, personal leave to your leave

is your leave.

We had to revamp some our policies so they were trauma-

informed for our employees for treatment, time off; not a
typical leave or leave of absence policy.
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Participant Quote Initial code Second cycle code

P4 Gates on premises Safety Precautions
P5 If someone said they felt unsafe, it was just the default that Voicing safety concerns
you trust them.

It was if you don’t feel safe, you’re not.

Preparedness in unsafe
Staff positioned in a way that they can get out. situations
De-escalation
I’ve had to break up fights.
Looking at trauma
We understand that this is often a product of trauma.
Looking at individual
Case by case basis, which I guess is trauma-informed cases through a trauma
practice by looking at it through that lens. lens
P1 They trust me to do my job. Employee Support/lack of
employee support
Always open.
P4 Supervisors are not aware of their own burnout Lack of awareness to
burnout

Final Themes

Code landscaping was utilized through a platform called Word Cloud Generator

([Link]). I noted in Chapter 3 that I would be using Wordle. Due to paid

subscription fees in Wordle, I chose to use Word Cloud Generator. I input text data from

the first cycle of coding into the Word Cloud Generator. The 10 most frequent words

generated were training, employee wellness, supervisor, policy, behavior, question,

participant, person, trauma, and staff. The words that had no significance were

eliminated from emerging themes.

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Figure 4

Word Cloud Generator Results

Code landscaping produced emergent themes, which I referenced back to the data

to determine which themes answered the interview questions. Pattern coding was used to

group similar data under each emergent theme and then used to determine the major

themes. I then applied theoretical coding to the remaining list of themes. From that list

emerged the final three themes of (a) there is a deficit/ambiguity in trauma-informed

curriculums and training in human service organizations, (b) more collaboration needed

is with other trauma-informed human service organizations/agencies, and (c) TIP should

be applied in human service organizations to better support employee wellness. Examples

of the first two rounds of coding and the determination of the final themes can be found

in Table 6.
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Table 6

Final Themes

Participant Quote Initial Code Second Cycle Code Final Theme

P2 Person presenting bad behavior? Understanding Importance of trauma- Theme 1: There is a
trauma behavior informed training practices deficit/ambiguity in
Are they being defiant? trauma-informed
Trauma- curriculums and training
Reactive attachment disorder informed in human service
Response organization
Look at their background.
Addressing
Client’s history victims with
trauma-
How is that affecting your behavior? informed
language
How is that affecting your
circumstances and symptoms?

What trauma looks like and how it

presents.

Different reactions and sometimes

the parents' reactions aren’t what
you would think.

We’re taught to be empathetic

listeners.

You don’t want to be bringing up all

that.
P4 Say, okay, what happened to you? Understanding Importance of trauma-
trauma behavior informed training practices
We don’t bring up anything that’s
going to initiate any bad feelings or Trauma-
anything like that. informed
Response
Trauma-informed and person- Addressing
centered or victim-centered go victims with
together. trauma-
informed
Training on first-person language. language
P6 Needs of the participants always Addressing Importance of trauma-
come first. victims with informed training practices
trauma-
informed
language
P5 The participant comes first . Addressing Importance of trauma-
. victims with informed training practices
trauma-
informed
language
P8 Person served Addressing Importance of trauma-
victims with informed training practices
trauma-
informed
language
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Participant Quote Initial Code Second Cycle Code Final Theme

P4 Community collaboration Multiple service Community Theme 2: More
Mobile crisis needs collaboration/collaboration collaboration needed is
with other trauma-
informed human service
P1 Defer to 911 Multiple service Community organizations/agencies
needs collaboration/collaboration
P2 Crisis hotline Multiple service Community
needs collaboration/collaboration
Law enforcement

P3 Sexual assault agencies Multiple service Community

needs collaboration/collaboration
Collaboration with other agencies
P5 Much larger focus on employee Employee Employee wellness focus Theme 3: Trauma-
wellness. Support/lack of informed practices
employee support should be applied in
Sensitivity to the trauma that their human service
employees were going through organizations to better
secondhand trauma and burnout support employee
and all the associated negative wellness
things with that.

Employee organization that was

focused on employee wellness.

Switched to lowering caseloads.

Making sure employee mental

health services were more readily
available.
P3 Switch from having sick leave, Employee Employee wellness focus
personal leave to your leave is Support/lack of
your leave. employee support

We had to revamp some of our

policies so they were trauma-
informed for our employees for
treatment, time off; not a typical
leave or leave of absence policy.
P4 Gates on premises Safety Precautions Employee wellness focus
P5 If someone said they felt unsafe, Voicing safety Employee wellness focus
it was just the default that you concerns
trust them. It was if you don’t feel
safe, you’re not.

Staff positioned in a way that they Preparedness in

can get out. unsafe situations

I’ve had to break up fights. De-escalation

We understand that this is often a Looking at trauma

product of trauma. behavior

Case by case basis, which I guess Looking at

is trauma-informed practice by individual cases
looking at it through that lens. through a trauma
lens
P1 They trust me to do my job. Employee Employee wellness focus
Support/lack of
Always open. employee support
P4 Supervisors are not aware of their Lack of awareness Employee wellness focus
own burnout. to burnout
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Participant Quote Initial Code Second Cycle Code Final Theme

P8 I think a lot of workers are not Employee Employee wellness focus
being taken care of. They’re Support/lack of
being pushed to the side. employee support
P8 Okay, so we have de-escalation De-escalation Employee wellness focus
strategies. strategies used to
individuals served

Evidence of Trustworthiness

Credibility

After each interview, I reviewed the data gathered and took notes of my thoughts

on the data collected to further establish credibility (Johnson et al., 2020; Starks &

Trinidad, 2007; Tufford & Newman, 2010). I also made notes throughout the interviews

as well. I found that the interview responses brought up feelings about my own

experiences in the field. I was mindful of those experiences and utilized reflexive

journaling to control bias. I then referred back to the interview questions and the

responses given by each participant taking careful note of the new data gathered.

I also established credibility by ensuring the interview information was accurate

using member checks. Each participant was emailed a copy of their transcript to review

for accuracy (Candela, 2019). Two participants responded that their transcripts were

accurate. One participant notated one correction in their transcript which I corrected. The

transcripts for all other participants were assumed to be correct as they did not respond

back after receiving their transcript via email.

Transferability

Transferability was established by providing a detailed description of the research

study method in Chapter 3, which I followed throughout my interactions with potential

participants, during interviews, after interviews, and through the data analyses. I collected
 99
participant demographics and provided descriptives of my sample to 1) determine if the

demographics of my sample were in line with the larger population of human service

workers and 2) determine if my sample was generalizable to the larger population

described in Chapter 3 as recommended by Chowdhury (2015). I also determined the

generalizability of my study results by using purposive sampling where each participant

needed to meet the inclusion criteria. A thorough description of the characteristics of the

sample was included and the results of this study should only be generalized to those who

would meet the inclusion criteria of the study and are similar to the demographics of my

sample.

Dependability

I established an audit trail through the recordings of interviews, ensuring

transcript accuracy, and ensuring that my researcher notes were accurate before using

them during data analysis and interpretation of results. I took careful notes to record my

observations from the interviews and my thoughts and interpretations about my dialogue

with the participants to ensure dependability (Carcary, 2020; Mulhall, 2002). My notes

helped to provide insight into the process of the study and the research findings for

consistency (Golafshani, 2003; Phillipi & Lauderdale, 2018).

Confirmability

Confirmability was established through my explanation of the different phases of

data coding and theming of the data. I provided a detailed description of how I conducted

the study and coded my data so that other researchers could replicate this study and the

coding decisions. I referred to all records, electronic and written when completing the
 100
data analysis, results, and interpretation of those results as recommended by Anney

(2014). The coding procedure used in this study allowed me to remain objective because

I followed specific coding guidelines that I established before collecting and analyzing

the data and attempted to control my biases through the use of field notes that I referred

to often.

Results

The research question for this study was: What are case manager perceptions of

trauma-informed practice and policy in human service organizations? The final three

themes derived from the data that answer this question were Theme 1: There is a

deficit/ambiguity in trauma-informed curriculums and training in human service

organizations; Theme 2: More collaboration needed is with other trauma-informed

human service organizations/agencies and Theme 3: TIP should be applied in human

service organizations to better support employee wellness.

Theme 1: There is a Deficit/Ambiguity in Trauma-Informed Curriculums and

Training in Human Service Organizations

All participants were asked to describe the trauma-informed policies at their

organization. I received a variation of answers to describe the type of trauma-informed

training they received, training duration and requirements, and trauma-informed training

that did not always align with “best practices” or what the employees of the organization

were directed to do in practice. An example of the misalignment was in the action of P1

who chose to skip question 1 which was: Describe the trauma-informed policies at your

organization. Question 1 was used to understand what trauma-informed policies are

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already in place at the participants’ organizations. P1 may not have a clear understanding

of what the trauma-informed policies are at their organization. The participant was asked

if they wanted to revisit question one and I read the question aloud again. P1 responded:

“We can just leave it as is.” The lack of response indicates that the participant was not

comfortable discussing the topic of trauma-informed policies supports there being a

deficit or some ambiguity in trauma-informed curriculums and training in human service

organizations.

It should be noted that participant answers indicated that they did not fully

understand the difference or alignments between TIP and trauma-informed policy other

than just the recognition that a person has gone through trauma. For example, when asked

to describe TIPP at their organization, P2 responded, “A lot of the education presented

helped you recognize not just symptoms, but looking at the background, looking at not

just what you're seeing the client present with, but what is the client's history.” This

indicates that the training may be lacking in how to differentiate between TIP and

policies when working with a client who has experienced trauma. This was also seen in

the response of P5 who stated, “So, we had training on person first language, the mental

and physical effects of trauma on children. So, it was the practices, I guess just all of our

practices were steeped in it.” I found that participants used “practices” and “polices”

interchangeably throughout the interviews without really communicating that the two

things are different.

Participants also indicated that the basic skills related to identifying signs of

trauma were communicated but little other than that. P8 stated, “We don’t really have
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trauma policy. I mean we have the basic stuff… we do a person-centered plan and we

took a look at terminology because some words can be triggering for them and cause

behaviors.” There also seems to be a lack of documentation related to trauma-informed

policies that should be governing TIP in organizations. P6 stated, “We don’t specifically

have what I would call trauma-informed policies written down…We have core

competency training, we’re confidential, and the participant always comes first.”

Participants did discuss that trauma-informed training is important and there is a

need for more trauma-informed curriculums and training in human service organizations.

For example, P2 stated, “Education is big. Look at things from a developmental trauma

perspective.” They discussed issues with training specifications, types of training, trauma

recognition, the lens through which case managers and organizations see trauma, and

additional education case managers felt they needed. P6 stated that they wished there was

trauma more training available.

I wish there was more training available just on that trauma itself, except for the

four or five hours that are mandated…Some people, I think they pick stuff

because it looks like it's easy and I just want to get my 16 hours out and I wish

people would be more, if it was more across the board, we're getting kind of the

same sort of stuff, more consistent.

P3 stated “more education” was needed to better serve victims of trauma and thought

their agency would better benefit from adding policies from the Substance Abuse and

Mental Health Services Administration (SAMHSA). P3 stated, “People don’t tend to see

those things that come out of substance abuse disorders as specific to that type of policy
 103
or that type of care.” The participant was referring to incorporating policies from

substance use disorders in trauma organizations. SAMHSA is a governmental agency

designed to promote mental health, prevent substance misuse, and provide treatment and

support to ensure equal access and better outcomes (SAMHSA, n.d..).

P8 discussed how important the use of terminology in TIC due to participants not

wanting to be referred to in certain ways because it was triggering to them.

Even with terminology because some individuals were coming saying that I don't

like being called this or I don't like being called that… So more so kind of just

took a lot of terminology away… I guess I could say that like that because some

words can be triggering for them and it could cause behaviors.

Education and training in trauma terminology may provide a more effective way to

communicate with the population served as to not retraumatize those individuals.

Theme 2: More Collaboration Needed is With Other Trauma-Informed Human

Service Organizations/Agencies

Human service professionals often need to engage in the process of triage to

determine what the client’s most important needs are to be able to effectively refer to

other organizations or agencies. While a human service professional is expected to be

able to determine whom to collaborate with, the ability to collaborate between

organizations and agencies can be difficult due to the differing training, purpose, and

culture of that other organization or agency. Participant 3 responded, “So we would have

to triage that, try to determine what other agencies. A lot of this is about collaboration

with these individuals because it would be after hours.” Participants discussed their
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efforts to collaborate with other organizations and services when serving the needs of

their respective populations. For example, working with law enforcement was mentioned

multiple times.

Despite the identified need to collaborate with other organizations and agencies,

the way to accomplish this is often not clear or easy. For example, P1 discussed how

training for police officers can actually be counterintuitive to the situation,

The police didn't understand, deaf culture, didn't understand how animated at

times a deaf person can be, especially if they're agitated or upset and they would

not have gotten the help, the mental health help that they needed had it not been

for us finding out that this person had been arrested. The thing was this person

had been arrested for several days in the county jail with no interpreter, no access

to a video phone. And that's the sort of thing that needs to change.

Participants spoke of other agencies such as a mobile crisis unit, sexual assault agencies,

crisis hotline, and other community agencies as groups that they work and communicate

with in order to provide services. The participants identified the need to work with

outside organizations/agencies and the need for these organizations/agencies to have

knowledge about the respective populations in which they provide this service.

For example, P2 stated, “If I go to a school, educate the school on that, if I'm talking to a

psychiatrist, I educate the psychiatrist on that. Yeah, I think a lot of what we do is care

coordination. It’s having that group conversation. I think that helps.”

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Theme 3: TIPP Should be Applied in Human Service Organizations to Better

Support Employee Wellness

The importance of the organization ensuring employee wellness was provided by

multiple participants since working with individuals who have experienced trauma can

result in burn-out and vicarious trauma being experienced by professionals. P4 stated,

“And no matter what it is, everybody seems to need boundary training, including

ourselves as helpers who say yes to everything, you know, have to look within… And I

think us as providers it’s so important as well.” This need for self-care and boundaries

was supported by P3 who responded,

So, we actually had to revamp some of our policies so that they were trauma-

informed for our employees for treatment time off. Those are the types of policies

that can help someone. It's not a typical leave of time, leave of absence

policy…So we had to actually change some of our policies when the number, we

had an employee assistance program, and annually we would analyze

anonymously the types of calls that were fielded over to the employee assistance

program. So, what was happening were a lot of substance use disorder cases for

employees.

Applying TIP in human service organizations should not just be towards clients but also

towards those employees who work with the clients. Boundaries are an important part of

creating work life balance and can promote employee wellness (Laker & Roulet, 2021).

This was also supported by P5 who stated,

I also think one thing that the organization got better at as I stayed there longer
 106
was sensitivity to the trauma that their employees were going through secondhand

trauma and burnout and all the associated negative things with that. And there was

a much larger focus on employee wellness and really understanding it in a job like

this. But I think the way a meaningful change came is there was an employee

organization that was focused on employee wellness and so it switched to

lowering caseload counts and making sure employee mental health services were

more readily available distributing less of therapists who work with therapists…

They’re quitting cause they can’t handle the work.

Participant 8 spoke about how professionals in their organization did not believe that the

organization cared for them the same way that they cared for clients.

The only thing they tell you is send them to the hospital and they pay leave that's

paid. When it comes to crisis and trauma and all of that, I think a lot of the

workers are not being taken care of. I think that they are being pushed to the side,

so if something happens to them, they'll just get somebody in their place. I don't

think that they care. I handle employees with care, the work, environmental care.

They don't.

There were discussions about the emotional and mental aspects of employee

wellness. Physical safety is reported to have an impact on employee wellness and

posttraumatic symptoms (Rosenthal et al., 2018). Healthcare workers who are affected by

verbal and physical violence miss work and consider leaving their jobs (Rosenthal et al.,

2018). However, the participants made statements that referenced physical safety and

physical health as well. I revisited P4’s statement on safety: “…and so if you don't feel
 107
safe, we have panic buttons in places that you can press alarm systems everywhere that

you can press.” P4’s statement led me to believe that the organization took their

employee’s physical safety into consideration and the employees are believed when they

make statements about their safety. It reinforces the assumption that employees are more

likely to remain on their jobs when their physical safety and mental health are a priority.

P5 made a statement that their organization responded with "sensitivity to the

trauma that their employees were going through secondhand trauma and burnout and all

the associated negative things with that.” The organization made sure that “mental health

services were more readily available, lowered caseloads, and stopped labeling sick

leave.” The organization labeled their leave as “personal leave” and employees could use

it the way they needed and they were not questioned about it.

P3 responded, “Supervisors are not aware of their own burnout and need for

developing.” P3’s response highlights the need for supervisors to recognize when they

are experiencing burnout and how they can continue to develop in the field. Burnout is

mental, physical, and emotional exhaustion which supports the theme that TIP should be

applied in human service organizations to better support employee wellness.

Summary

The purpose of this generic qualitative research study was to describe and

understand case managers’ perceptions of TIPP across organizations and services. I

conducted eight semi-structured interviews to gather data from participants. The answer

to the research question What are case manager perceptions of trauma-informed practice

and policy in human service organizations was that there is a deficit/ambiguity in trauma-
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informed curriculums and training in human service organizations (Theme 1), more

collaboration is needed with other trauma-informed human service

organizations/agencies (Theme 2), and TIP should be applied in human service

organizations to better support employee wellness (Theme 3). In Chapter 5, I discuss

interpretation of the findings, limitations of the study, recommendations for future

research, and implications for social change.

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Chapter 5: Discussion, Conclusions, and Recommendations

The purpose of this generic qualitative research study was to d escribe and

understand case managers’ perceptions of TIPP across organizations and services.

Researchers found that victims can feel retraumatized due to the response they may

receive from victim-serving agencies (Becker-Blease, 2017; Helpingstine, 2023;

SAMHSA, 2014). Researchers have highlighted numerous implementation efforts of

TIPP, but describing case managers’ beliefs and attitudes about the practices and policies

of their organization may help to inform human service agencies on best practices,

policy, and training needs (Bryson et al., 2017; Ezell et al., 2018; Helpingstine, 2023).

The research question that guided this study was “What are case manager perceptions of

trauma-informed practice and policy in human service organizations?” The three themes

that were derived from the collected data that answer this question were (a) there is a

deficit/ambiguity in trauma-informed curriculums and training in human service

organizations, (b) more collaboration is needed with other trauma-informed human

service organizations/agencies, and (c) TIP should be applied in human service

organizations to better support employee wellness. In Chapter 5, I provide an

interpretation of the findings in the context of the theoretical framework as well as the

literature review, and I discuss limitations of the study, recommendations, and

implications for practice and positive social change.

Interpretation of Findings

Interpretation of Findings in Context of the Theoretical Foundation

EST was utilized as the theoretical framework for this study. There are a variety
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of ways that the system levels in this theory explain how individuals interact with the

societal systems around them and how these interactions affect the individual

(Bronfenbrenner, 1979). Experiences with certain “helper” groups have the potential to

trigger and retraumatize victims of trauma if those helper groups are not aware of the

potential to retraumatize victims when providing the support (Hӓrkӧnen, 2007; Pazderka,

2021). When an individual is a victim of some type of trauma, the system level where the

trauma occurred is not the only level where the effects of the trauma exist for the

individual. Instead, the experience that resulted in the trauma can vicariously exist in

other levels and retraumatize victims based on the interactions they have with systems

within those other levels (Bronfenbrenner, 1979).

Theme 1: There is a Deficit/Ambiguity in Trauma-Informed Curriculums and

Training in Human Service Organizations

The point of care where individuals and families meet with case managers in

human service organizations is considered the microsystem level (Abrahamson et al.,

2020; Kosnik & Espinosa, 2003). At the microsystem level, clients and case managers

interact closely, and there is a high possibility that these interactions could retraumatize

clients if the case manager is not cautious in those interactions (Abrahamson et al., 2020;

SAMHSA, 2014). This is an intimate relationship where the client is sharing difficult

information and is looking for support and “solutions” from the case manager.

Participants in my study provided information that indicated that they are not receiving

adequate trauma-informed training to provide effective TIC to individuals and families to

avoid retraumatization at this level. However, even the training may not fully help the
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case manager from being able to completely avoid retraumatizing clients, which can be

seen in the statement from P8:

Even with terminology because some individuals were coming saying that I don't

like being called this or I don't like being called that… I guess I could say that like

that because some words can be triggering for them and it could cause behaviors.

P4 also similarly stated, “We were mimicking behaviors of perpetrators by not giving

them choices, by having curfews which wouldn’t allow them work schedules which we

thought were for their safety.” It is therefore important that case managers receive

training on how to recognize the signs of trauma and retraumatization as well as training

on how to adjust their interactions with clients if the case manager suspects that the

interactions with the client could result in retraumatization. This training should provide a

variety of scenarios and address how to adjust in order to meet the individual needs of a

client. It may also be beneficial to have training include role play opportunities to put into

practice the skills that the case managers are learning about to avoid retraumatization.

Overall organizational practices are found at the exosystem level

(Bronfenbrenner, 1977; Martinello, 2019). Case managers who work with individuals and

families are responsible for carrying out TIPP that are developed at the exosystem level

of the organization but implemented at the microsystem level. The importance that an

organization assigns to the concept of TIPP can be seen if the organization has prioritized

these practices as part of daily operations and interactions (Bloom, 2006; Galvin et al.,

2022). However, sometimes these things are not documented but are “unwritten rules” of

the organization. When these types of practices are not documented well, and/or the staff
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have not been trained effectively on these practices, then it is easy to forget the

importance of these practices and they may not be implemented. For example, P8 stated,

“We don’t really have trauma policy. I mean we have the basic stuff. If you need help do

this or if you have this, they don't really have any .” P6 also similarly stated, “We don’t

have what I would specifically call or trauma-informed policies that, um, that are like

written down.” P1 indicated that, even if written down, the complexity of the policies can

make them difficult to effectively use:

So, I think trauma-informed policies are very broad, and I think that

administrators, legislators, and even advocates get lost in the language of it and

maybe don't really understand what it means. And the continuous cycle of trauma-

informed policies and care for our communities, it's not an easy fix. It's not

something that's going to change with one policy. So, I think that there needs to

be more education on what these words really mean.

It was clear that there is confusion and uncertainty about these policies. If a policy and/or

procedure are too complex, too vague, or unclear, it can result in an employee to just “do

the best that they can” in a situation instead of knowing what to do per policy. This can

result in confusion for the case manager when providing services to clients as they are not

sure what exactly they should be doing in relation to trauma.

HHS (n.d.) has direct influence over public health policies, laws, education and

training, patient rights, and programs and services carried out in human service

organizations. The HHS does not have rules regarding TIP, but they support the trauma-

informed approach and outline the six key principles to becoming trauma-informed
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(SAMHSA, 2020): (a) safety; (b) peer support; (c) trustworthiness and transparency; (d)

collaboration and mutuality; (e) cultural, historical, and gender issues; and (f)

empowerment, voice, and choice. SAMHSA (2020) contends that mental and physical

health is negatively impacted by trauma. Therefore, human service organizations should

adopt organizational policies consistent with the state or federal government. As the

participants talked about the curriculum and training related to TIP in their organization,

there was little consistency seen in curriculums and training across different settings.

Participants shared that policies and practices are dependent on the needs of the clients

that an organization serves, but they indicated that they would like more of the HHS and

SAMHSA tenets put into curriculum and training as well as consistency across human

service organizations as a whole (macrosystem). P3 specifically spoke about wanting to

include specific policies from SAMHSA:

So, SAMHSA has some really great policies, but again, because people don't look

at the entire picture, they tend to see those things that come out of substance use

disorder as specific to that policy or that type of care. And if agencies aren't

working with that particular clientele, they're not incorporating some of these

things. They're really much more broad-based. So, I think that’s a great example

of a policy that can be implemented across all of the departments within a state,

not just one particular department. Not just health, not just addiction services, not

just mental health not just children’s services. These should be broad-based

policies.

Governmental departments (HHS) and professional organizations (such as SAMHSA)

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have policies, procedures, and recommendations of best practices in the field, but these

are not always implemented in an individual organization (Huo, 2023). These approaches

and stances on TIP, which were referred to by participants, add credibility to the

importance of macrosystem-level policies on service delivery and organizational wellness

(Bloom, 2016; SAMHSA, 2014). Yet not all organizations are providing available

training and education to staff. The lack of necessary training will negatively affect staff

and the populations that they serve (SAMHSA, 2014; Milner et al., 2019; Zhenjing et al.,

2020).

Theme 2: More Collaboration is Needed with other Trauma-Informed Human Service

Organizations/Agencies

There are multiple organizations and agencies that provide support and service to

victims of trauma including courts, nonprofit agencies, law enforcement agencies,

schools, and hospitals, which function within, and across, the microsystem, mesosystem,

exosystem, and macrosystem (Katirai, 2020). In addition, changes take place over time

based on these interactions between organization/agencies, how society changes, and

these are reflected in the chronosystem (Chiarelli-Helminiak et al., 2022). Participants in

my study provided information that indicated more collaboration is needed with other

human service organizations to ensure individuals who have been traumatized continue to

be supported and have access to adequate services. If not provided with the continuum of

care, individuals run the risk of retraumatization, or they may not receive the necessary

treatment or support (Meyer et al. 2007; Pittenger et al., 2015). An example of this can be

seen in a statement by P1 who provided an example of how law enforcement

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retraumatized a victim because they were not knowledgeable about the deaf population

and how to best serve them:

And for social workers, mental health providers, emergency personnel, anybody

that’s not involved in the community, just learning about the culture that needs to

happen…The police didn’t understand, deaf culture, didn’t understand how

animated at times a deaf person can be, especially if they’re agitated or upset and

they would not have gotten the help, the mental health help that they needed had it

not been for us finding out that this person had been arrested. The thing was this

person had been arrested for several days in the county jail with no interpreter, no

access to a video phone. And that’s the sort of thing that needs to change.

The example highlights the importance of collaborating with other agencies that may be

more knowledgeable about the populations as they work with this population more often.

In this situation, if law enforcement had been able to closely collaborate with another

organization that works closely with the deaf community, law enforcement could have

done better in providing services and lessened the possibility of retraumatization. EST

describes the direct connection between the individual, organization, and the direct

environment in a situation which is the microsystem (Crawford, 2020). A positive

encounter could foster trust between the organization and the victim, increasing the

likelihood of them returning to the organization for further assistance. However, if they

have a negative interaction within this microsystem then they may not feel comfortable

with the organization in the future (Maiorano et al. 2023).

At the mesosystem level, the interactions are between multiple microsystems

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(Bronfenbrenner, 1979). There can be multiple human service professionals interacting

with one another to provide adequate care to an individual. It may be deemed important

for a doctor to collaborate with their patient’s case manager, a mental health provider, an

attorney, law enforcement, and/or another agency to coordinate care and ensure that gaps

in care do not exist (multidisciplinary teams; Gobet, 2018). For example, P2 stated ,

I don’t really know how to help this family. What do you all think? And then the

response is this multidisciplinary response. Whereas you've got other social

workers on the call, you have other doctors, like medical doctors, there are

psychiatrists. There were people who were lawyers that were on the call that

actually had background with that. And so, it allows each of us that needs help to

get help from different perspectives. And it’s really useful.

Collaboration with other agencies has been found to support better outcomes for the

client (Drexler, 2020). However, although many agencies/organizations have attempted

to adopt a multidisciplinary approach, not all have done so even though it would be

helpful to have multiple professionals involved to deliver TIC and offer varying

perspectives to limit the gaps in services (Gobet, 2018).

Theme 3: TIP Should be Applied in Human Service Organizations to Better Support

Employee Wellness

According to Bronfenbrenner (1979), EST illustrates how social, environmental,

political, and cultural systems impact human development. EST best supports the theme

on employee wellness because it describes how human service professionals can be

impacted by their work environment, how they impact their work environment, and how
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they carry the impact of their work into their personal lives (SAMHSA, 2014; Milner et

al., 2019; Zhenjing et al., 2020). Human service agencies should apply TIP to better

support employee wellness as vicarious trauma is an issue that has been found to result in

burnout and attrition of human service professionals (Bloom, 2006; Dombo & Blome,

2016). Many participants in my study discussed not feeling safe and/or not feeling

supported by their employer. P8 did not feel like they were protected by their

organization from behaviors exhibited from clients and stated , “Some of them just talk or

they'll curse at you to being combative and hit …When it comes to crisis and trauma and

all of that, I think a lot of the workers are not being taken care of .” This participant stated

that the organization would send them to the hospital if warranted, but they did not care

beyond that point.

Due to not having the appropriate support or programs to deal with the stressors

of serving human service organization clients, many case managers may develop their

own destructive behaviors, often turned inwards, due to the vicarious trauma and the

secondary traumatic stress they experience (Ashley-Binge & Cousins, 2020). Individuals

may experience anxiety and depression (SAMHSA, 2020) which can disrupt the family

unit creating stress in the home (Piotrowski et al., 2019). The development of substance

abuse issues is common in employees who work with individuals who have experienced

trauma (International Society for Traumatic Stress Studies, 2016). This was evidenced in

this study as in the statement of P3, “So what was happening were a lot of substance use

disorder cases for employees.” P3 also reported that their organization changed their

policies to accommodate the staff because they were experiencing substance use
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disorders. The organization no longer made a distinction between sick time and annual

time (exosystem level policy change).

P3 further stated, “Supervisors are not aware of their own burnout and need for

developing.” The trauma-informed approach is a top-down concept meaning that it will

begin with the organization and transfer to all other staff. Case managers are not directly

involved in the relationship supervisors have with directors/and or the organization.

However, case managers are affected by supervisor burnout and professional

development at the mesosystem level. This can be seen in the statement of P5 who

reported, “They’re quitting cause they can’t handle the work.”

Human service professionals who are not happy and have low morale may be

more likely to take their work issues and problems home with them (to their

microsystem). When employers value their employees, employees have better outlooks

on their jobs and their productivity is better (Abbott, 2022; SAMHSA, 2014). It may be

beneficial for employers to encourage work-life balance for their employees, better

manage client caseloads, establish self-care in the workplace, and hire staff that are

supportive to each other as well as clients (Abbott, 2022; SAMHSA, 2014). Employee

assistance programs (EAP) were created to meet the needs of employees experiencing a

wide array of stress-related symptoms that affect job performance (APA, 2006). EAP

programs at the exosystem level can affect changes in the microsystem and the

mesosystem of an employee by addressing the stressors in the workplace and providing

support to employees to better deal with those stressors (Bronfenbrenner, 1977; Newman

& Newman, 2020).

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Interpretation of Findings in Context of the Literature Review

Theme 1: There is a Deficit/Ambiguity in Trauma-Informed Curriculums and

Training in Human Service Organizations

Researchers indicated that TIC and TIP are

terms used interchangeably throughout the field (Bryson et al., 2017; Classen & Clark,

2017; Portman-Thompson, 2020; Purtle & Lewis, 2017; Sullivan et al., 2018; Tebes et

al., 2019). This study highlighted case manager perceptions of TIPP in human service

organizations. There was also an emphasis on the social structures and processes that

retraumatize victims. I found that case managers in my study did not think that they were

receiving enough trauma-informed training. According to Schippert et al. (2021), the

deficits/ambiguity in trauma-informed curriculums and training puts case managers at

risk of retraumatizing victims. The effectiveness of TIPP is heavily dependent upon the

prioritization of TIC by leadership staff that supports advanced training (Bryson et al.,

2017).

Throughout the study, I found that participants also used the terms trauma-

informed practice and trauma-informed policy interchangeably. When asked to describe

TIP in their organization, P2 responded, “A lot of the education presented helped you

recognize not just symptoms, but looking at the background, looking at not just what

you're seeing the client present with, but what is the client's history.” P2’s response added

credibility to support the theme but further highlighted that participants may not

understand the difference or alignment between TIP and trauma-informed policy. The

response referred to recognizing symptomology, but there was no real description of

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practice or policy.

Researchers reported that TIP are important in ensuring trauma is addressed

appropriately to boost positive outcomes for clients (Chaffouleas et al., 2016; Maynard et

al., 2019; SAMHSA, 2014). When human service professionals do not understand the

difference, or alignment, between TIP and trauma-informed policy, it can be concluded

that they lack the necessary training or there is some confusion on what these terms

mean. Therefore, the lack of knowledge and training can cause retraumatization for

clients inadvertently (Schippert et al., 2021).

Participants also expressed a need for more trauma-informed training which

indicates that they are aware of the potential for retraumatization of their clients and want

to know how to avoid this. For example, P6 stated,

I wish there was more training available just on that trauma itself, except for the

four or five hours that are mandated…Some people, I think they pick stuff

because it looks like it's easy and I just want to get my 16 hours out and I wish

people would be more, if it was more across the board, we're getting kind of the

same sort of stuff, more consistent.

This statement is consistent with the findings of researchers who indicate that training is

necessary for clinical and non-clinical staff in relation to the implementation of TIPP

(Bargeman et al., 2021; Menschner & Maul, 2016). This statement also shows that there

are deficits/ambiguities in trauma-informed training and curriculums because some

participants were not sure of whether they had TIPP at their organization. For example,

P8 responded, “We don’t really have trauma policy. I mean we have the basic stuff… we
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do a person-centered plan and we took a look at terminology because some words can be

triggering for them and cause behaviors.” P6 provided a similar response regarding the

ambiguity within their organization about having official trauma-informed policies and

procedures, “We don’t specifically have what I would call trauma-informed policies

written down…We have core competency training, we’re confidential, and the participant

always comes first.” Again, one may assume that there is a deficit/ambiguity of TIPP in

human service organizations due to the lack of knowledge of trauma-informed policies in

their organization.

Theme 2: More Collaboration is Needed with other Trauma-Informed Human Service

Organizations/Agencies

Collaboration has been identified as one of the six principles of TIP (CDC, 2023;

Isobel & Edwards, 2017; SAMHSA, 2014). Collaboration promotes education and the

sharing of knowledge (Green & Johnson, 2015). Participants in my study identified

situations in which more collaboration is needed with other trauma-informed human

service organizations as services are currently very departmentalized. For example, P2

stated, “If I go to a school, educate the school on that, if I’m talking to a psychiatrist, I

educate the psychiatrist on that. Yeah, I think a lot of what we do is care coordination.

It’s having that group conversation. I think that helps.”

Relationships are very important to the collaboration process. Relationships with

other organizations should prove beneficial to helping trauma victims heal. Researchers

emphasized that trust is developed through stable, reliable interpersonal connections

(Charuvastra & Cloitre, 2008; Collin-Vezina et al., 2020). The research findings further
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support the scholarly research that healing takes place within relationships (Wilson et al.,

2013; Leibman, 2020). Since trauma causes a disruption in healthy relationships, it is

important for clinicians to build an alliance with the client, as well as other professionals,

to foster resilience and psychological safety for that client (Bath, 2015; Liebman, 2020).

Efforts to collaborate can be counterintuitive if the organizations/agencies are not

properly trained. P1 provided an example of how an individual was affected by a

collaborative agency:

And for social workers, mental health providers, emergency personnel, anybody

that's not involved in the community, just learning about the culture that needs to

happen…The police didn't understand, deaf culture, didn't understand how

animated at times a deaf person can be, especially if they're agitated or upset and

they would not have gotten the help, the mental health help that they needed had it

not been for us finding out that this person had been arrested. The thing was this

person had been arrested for several days in the county jail with no interpreter, no

access to a video phone. And that's the sort of thing that needs to change.

P1’s response was a significant case of retraumatization. The example of communication

with the agency highlighted deficits in trauma-informed training which supports the need

for collaborative organizations/agencies to be trauma-informed. This finding supports the

scholarly research that the lack of knowledge, awareness, and training are elements in the

healthcare system that may perpetuate retraumatization (Schippert et al., 2021).

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Theme 3: TIP Should be Applied in Human Service Organizations to Better Support

Employee Wellness

Psychological and physical safety of clients and staff is important in human

service agencies and organizations as the staff can be affected vicariously because of the

information and interactions they have with clients who have experienced trauma

(Sullivan et al., 2018; Wolf et al., 2013). Safety and wellness for employees and clients

can be achieved by promoting the development of healthy boundaries between clients and

human services providers (Levenson, 2017; Wolfe et al., 2013). For example, P4 stated,

“And no matter what it is, everybody seems to need boundary training, including

ourselves as helpers who say yes to everything, you know, have to look within… And I

think us as providers it’s so important as well.” When boundaries are not well

established, it becomes easier for the trauma to transition from the client to the human

service provider which can result in the boundaries continuing to erode to the point where

the provider cannot effectively work with the client (Lee & Miller, 2013; Walker, 2004).

P4 stressed the importance of having case managers not saying yes to everything, which

can help with work-life balance. Work-life balance is important to achieving employee

wellness and boundaries are also very important to achieving this for employees (Laker

& Roulet, 2021).

Unfortunately, individuals who work in helping professions are often driven by

the desire to help others and this can result in them being less effective in their work due

to diminished boundaries which can lead to stress and burnout (Chiarelli-Helminiak et al.,

2022; Lee & Miller, 2013). It is important for an organization to not only worry about the
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well-being of those that they serve but also their employees. The implementation of such

policies reinforces boundaries and employee wellness so that human service professionals

may achieve work-life balance. P3 stated that their organization made sure “mental health

services were more readily available, lowered caseloads, and stopped labeling sick

leave.” However, P3 shared that these policy changes only came as a result of substance

use cases amongst case managers, which suggests organizations may be reactive instead

of proactive. If an organization is reactive to the needs of their employees it also may

mean that they are not following trauma-informed policies and procedures for their

clients (Menschner & Maul, 2016). TIP is being considerate of the staff in the care setting

as well as the client (Isobel & Edwards, 2017; Leitch, 2017). Organizations with cultures

more supportive of trauma-informed employees are more effective in implementing TIPP

changes in the organization (Dublin et al., 2021). P5 reported that case managers were

quitting. P5 stated, “They’re quitting cause they can’t handle the work.” According to

P5, case managers at their organization were experiencing work-related stress.

Limitations of Study

The ability to recruit research participants in a timely manner who met the

inclusion criteria was a potential limitation discussed in Chapter 1. It was a partial

limitation for the study as recruitment for this study began just before the Thanksgiving

holiday. I was recruiting throughout Thanksgiving, Christmas, and the New Year and

responses were few. After those holidays, recruitment picked up and I was able to get the

necessary number of participants to meet saturation.

A second limitation for the study was the weaknesses of purposeful convenience
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sampling because it can result in a sample that would produce a potentially homogeneous

sample which then limits who the results can be generalized to (Andrade, 2020). Eight

participants were interviewed before I reached saturation and was given permission to

end data collection. Only one of the eight participants was male and only one was

Black/African American. Six participants had worked in non-profit organizations. Five of

the eight participants had a bachelor’s degree. Because the sample of participants was

homogeneous, generalization of the results needs to be done cautiously and future

researchers should attempt to address this limitation.

Another limitation of the study was that participants often used the terms trauma-

informed practice and trauma-informed policy interchangeably. It was assumed that

participants would understand that TIP and trauma-informed policy were different as

understood by the researcher, but it was apparent that the participants did not necessarily

differentiate the two as I did. I attempted to mitigate the extent of this limitation by

providing a thorough explanation of how I conducted the different levels of coding and

arrived at the final themes that answered the research question and then interpreted those

results. However, future researchers should attempt to address this limitation as well.

Recommendations

I would first recommend that future researchers attempt to access and gather data

from a more heterogeneous sample. The participants in my sample were very similar to

one another (homogeneous) and this could have resulted in my reaching saturation in the

data prematurely when compared to a more differentiated pool of participants. Therefore,

the results of my study may not be generalized to the population of human service case
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managers outside of those that are similar to the sample from my study.

Another recommendation is due to participants having used the terms trauma-

informed practice and trauma-informed policy interchangeably. Participants did not make

a distinction between the two terms, which may have influenced the findings of this

study. Future researchers could help to understand the confusion in the use of trauma-

informed terminology and how to make the distinction between the two by providing

definitions of the two terms before collecting data. Providing these clarifications to

participants may result in data that is more specific and more actionable for researchers

and organizations.

While I attempted to d escribe and understand case managers’ perceptions of TIPP

across organizations and services through my study, there is still additional information

that should be gathered by future researchers. Examples would include specific types of

training that case managers receive related to TIC and the quality of those trainings. An

additional recommendation for future research is related to the quality of implementation

of these policies and practices within human service organizations. It would also be

recommended to conduct research with participants who are clients of these organizations

to study if the organizations are truly using these trauma-informed policies and

procedures as intended and how they are impacting the clients that are served by the

organization.

Implications

Implications for Positive Social Change

The problem that I attempted to address in this study, by providing additional

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understanding and knowledge of case managers’ perceptions of TIPP in human service

organizations, were the negative repercussions of retraumatization such as feelings of

being unsafe, anger, guilt, shame, depression, and secondary trauma at the hands of

organizations and systems that are meant to help victims of traumatic events due to those

organizations and systems not being based in trauma-informed approaches (Ezell, 2019;

Huefner et al., 2020; Medenhall et al., 2018; Mersky et al., 2019; Salloum et al., 2018).

Case managers are able to mitigate retraumatization through the appropriate use of TIPP,

which may provide trauma victims with support and encourage the healing process

(Levenson, 2017; Purtle, 2020). Furthermore, human service professionals may be able

to ward off the effects of vicarious trauma creating better work-life balance (Abbott,

2022; SAMHSA, 2014). Work-life balance promotes longevity in the workplace and also

makes it possible for professionals to better serve their clients (Brough et al., 2020;

SAMHSA, 2014).

My results indicated there is a deficit/ambiguity in trauma-informed curriculums

and training in human service organizations. Inadequate training leads to uncertainty in

skills and strategies needed to respond to individuals with trauma (Berliner & Kolko,

2016; Cook et al., 2019). Results also indicated that more collaboration was needed with

other trauma-informed organizations/ agencies. Lastly, the results indicated that TIP

should be applied in human service organizations to better support employee wellness.

Developing curriculums and trainings that provide more clarity or distinctions with

trauma-informed terminology may alleviate confusion for human service professionals

and can lead to confidence in their skills and abilities to assist individuals with trauma.
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Developing a standard trauma-informed process for human service organizations that

outlines specific measures to becoming a trauma-informed organization in addition to the

key concepts may standardize training procedures and terminology usage amongst human

service organizations and professionals creating more institutions of care that are trauma-

informed. Specific measures to becoming a trauma-informed organization may also be

inclusive of TIP that support employee wellness. It does not leave employers to

determine the standard for employee wellness, but rather implements a base model for

employers to address employee wellness with human service professionals who run the

risk of vicarious trauma.

Implications for Practice

Retraumatization has been found to have negative repercussions for victims of

trauma (Loughran & Reid, 2018; Pazderka et al., 2021; SAMHSA, 2014). The results of

my study support the work of previous researchers who indicated that TIP may not be

consistent across organizations and services (Carello & Butler, 2015; Champine et al.,

2019; Hanson & Lang, 2016). My participants shared that there are deficits/ambiguity in

trauma-informed curriculums and training, more collaboration is needed with other

trauma-informed human service organizations, and a need to apply trauma-informed

training practices to better support employee wellness. These are important takeaways for

human service professionals, organizations, and the overall human service profession.

There is a need at many different levels to address the deficits/ambiguity that exist

in trauma-informed curriculums and trainings. Increased training about TIPP may help

case managers better respond to trauma victims and prevent retraumatization (Brand,
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2016; Purtle, 2020). In addition, the information shared by participants in this study

indicated that there was a need to not only increase the amount of training on TIPP but

also to improve the quality of that training to better service clients. Increased quality of

trauma-informed curriculums and trainings that are consistent across the helping

professions may also be beneficial in helping human service, and other, organizations

collaborate with one another (Beck et al., 2022).

The potential to increase collaboration (quantity and quality) with other trauma-

informed human service, and helping, organizations is the second implication of practice

for my study. The results of this study could be used to help human service organizations

determine the areas of practice where collaboration is needed and how collaboration can

be beneficial to trauma populations. Beck et al. (2022) supported the collaboration of

trauma-informed agencies that share a common goal of serving a population. The

researchers shared that interagency training spaces provide for participants to be highly

trained and to take that training back to their organizations to invoke change at the

organizational level (Beck et al., 2022). Thus, collaboration is an important implication

for developing more consistent training across organizations in one locale which ensures

that the collaborating agencies are being trained the same to avoid miscommunication

and gaps in practice.

Finally, there is a potential implication for practice in relation to my finding that

there is a need to apply trauma-informed training practices to better support employee

wellness. Employee wellness is important when serving clients affected by trauma as the

professionals themselves can suffer from vicarious trauma from these interactions