Bridging Disciplinary Boundaries (January 11 - 14, 2007)

Purpose: Violence, and especially interpersonal violence, is common in the lives of people encountering human services, especially women with co-occurring mental health and substance abuse disorders. Given the prevalence of trauma and our lack of knowledge about how best to address trauma in human services, we need research about how to initiate and sustain services for trauma. In this paper, a dissemination of innovation framework is used to analyze change strategies used by nine demonstration sites in the Women Co-Occurring Disorders and Violence Study to implement a new practice, trauma-specific groups. Groups designed specifically to assist survivors to manage and address trauma symptoms can be characterized as innovations because they were entirely new to the sites implementing them, and are still rare within substance abuse and mental health settings. The paper addresses the following questions: 1. What aspects of the innovations created special dissemination challenges? 2. What strategies facilitated the implementation of trauma-specific groups at different levels of the systems in question and how did these change over time? 3. What barriers were encountered and how were they addressed?

Methods: Data from multiple sources (multi-year site and cross-site process evaluations, 4 semi-structured questionnaires completed by principal investigators, project reports, and focus groups with site representatives) were analyzed both deductively and inductively. Multiple investigators categorized activities by type, who was involved at what level of the participating systems, and how activities and challenges changed by phase of the project. We also coded the types of challenges encountered and how they were addressed in each site, and used constant comparison methods to compare and contrast these across sites and over time.

Results: We emphasize four sets of findings: 1) tasks important in each phase (decision to adopt the innovation, initiation, full implementation, institutionalization); 2) characteristics of the innovation that made implementation challenging and how these were addressed; 3) issues at four levels of the innovating systems (staff skills and knowledge, leadership and management issues, organizational culture and practices, external environment); and 4) cross-cutting strategies important for catalyzing complex changes. This last category includes the importance of working closely in all aspects with those who have experienced trauma; engaging in multidisciplinary, cross-level participatory planning throughout; making implementation issues and successes visible in multiple ways; and developing a common language and shared vision that centers on the importance of trauma.

Discussion/implications: Conceptualizing trauma groups as innovations within human service systems provides a framework to delineate what is needed to select, plan, implement, and sustain an innovation needed if we are to attend to the multiple types of trauma experienced by human service participants. The results represent 1) issues relevant for any new service, 2) special challenges related to addressing trauma, and 3) strategies important for making complex changes and modifying underlying paradigms. Although our emphasis here is on a particular intervention (trauma-specific groups), the results are relevant for many types or implementation research and illuminate how programs can become more trauma-informed (so that they can be welcoming places that do not exacerbate traumatic reactions).