Waterloo Region Trauma Service Initiative

Needs Assessment Report

October, 2013

A project funded by:

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About this Project
The Waterloo Region Trauma Service Initiative is a collaborative project to enhance trauma services in
the region. It involved community mobilization, needs assessment and action planning. This report
details the findings the needs assessment.

Funder: Ontario Trillium Foundation

Project Steering Committee

Jan Klotz, Sanguen Health Centre
Theresa Karn, Carizon Family and Community Services (Mosaic)
Ana Luz Martinez, KW Multicultural Centre
Cathy Read-Wilson, ACCKWA
Deborah Deforest, Self Help Alliance
Donna Dubie, Healing of the Seven Generations
Barb Ward, kidsLINK/Waterloo Region Coalition on Trauma-Informed Services
Helen Ramirez, Ph.D., Wilfrid Laurier University
Jonathan Lomotey, Ph.D., Lead Researcher, Novell Community Development Solutions
Julie Wise, Project Coordinator

Research Team
Jonathan Lomotey, Ph.D., Lead Researcher
James Popham, Senior Researcher, Centre for Community Based Research

Acknowledgements:
The Steering Committee and Research Team express their appreciation to OTF and all the agencies and
individuals who participated in and/or supported this project. This includes the participants in the
outreach groups, individual interviews, focus groups, the agency survey, and action planning forums.
They also thank former Steering Committee members: Colby Marcellus (formerly of ACCKWA) and Marty
Schreiter (formerly of KWMC) who played a major role in the initiation of this project.

For more information about this report, please contact:

Jonathan Lomotey, Ph.D.
Novell Community Development Solutions
113-50 Mooregate Crescent,
Kitchener, ON, N2M 5G6
jonathan@novellcds.org
www.novellcds.org

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Table of Contents
Executive Summary...................................................................................................................................... iii
Introduction and Background ....................................................................................................................... 5
Psychological or emotional trauma .......................................................................................................... 5
Response to trauma in Canada and the United States ............................................................................. 7
Models of service delivery ...................................................................................................................... 10
Overview of the Needs Assessment ........................................................................................................... 13
Purpose ................................................................................................................................................... 13
Needs assessment questions .................................................................................................................. 13
Approach and design .............................................................................................................................. 13
Participants ............................................................................................................................................. 13
Data gathering methods ......................................................................................................................... 14
Data analysis ........................................................................................................................................... 15
Findings ....................................................................................................................................................... 16
Populations that are affected by trauma................................................................................................ 16
Trauma services in the Region of Waterloo............................................................................................ 17
Gaps in trauma services .......................................................................................................................... 19
Barriers to accessing trauma services ..................................................................................................... 22
Conclusions and Recommendations ........................................................................................................... 25
References .................................................................................................................................................. 28

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Executive Summary
The purpose of the Waterloo Region Trauma Service Initiative was to explore the need for inclusive,
accessible and appropriate trauma services in the region and identify solutions. The main objectives of
the initiative were:
o To mobilize stakeholders towards enhancing capacity for inclusive, accessible and appropriate
trauma services in the Region of Waterloo
o To understand trauma service needs of affected populations in the region
o To document existing trauma services in the Region of Waterloo
o To identify gaps and barriers to trauma services
o To initiate an action plan for addressing the gaps and barriers identified

The initiative had three main components:

1. Community mobilization – to raise awareness and increase participation

2. Needs assessment – to document existing trauma services in the region, identify gaps in them
and ways to address the gaps
3. Action planning – to develop a region specific model for integrated, inclusive, accessible and
effective trauma services

Altogether, 205 people participated in this initiative. They included participants in individual and group
community outreach interviews, the needs assessment, and two action planning forums. Out of the 205
people, 77 participated in the needs assessment: 45 in an agency survey and 32 in focus groups. The
participants in the needs assessment were all adults: nine males, twenty females and three who
described themselves as transgendered or queer. The majority of agencies that participated in the
survey were located in Kitchener and Waterloo (66.6%); the rest were located in Cambridge, Ayr, Fergus,
St. Agatha, Elmira, New Hamburg, North Dumfries, St. Jacobs and Guelph. The findings of the needs
assessment are summarized below.

Findings
The needs assessment revealed that there are many client groups in the Region of Waterloo who are
affected by trauma. They include victims of rape, abuse, neglect, household dysfunction and violence;
people who are living with mental illness; people who are living with addictions; new immigrants and
refugees, especially people who have fled from war and conflict; people who are living with HIV and
AIDS; people who are homeless; people who are living with or at risk of Hepatitis C infection; and
Aboriginal people who are affected by historic trauma. Also affected are service providers and first
responders who are experiencing vicarious trauma.

The findings also indicated that there are several trauma services in the Region of Waterloo. However,
most of these services are concentrated in the twin-cities of Kitchener and Waterloo. The findings
further revealed several gaps in services and barriers to accessing them.

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The main gaps identified in the service system were:
o A lack of capacity in trauma treatment services
o Lack of awareness and understanding of trauma among support service providers – many
agencies in the region are not trauma-informed
o Limited communication and referral relationships among agencies

Other challenges identified in the service system were:

o Limited availability of resources, including insufficient funding for staffing and services
o Long wait-times created by the lack of capacity in service agencies
o Lack of cultural competency among service agencies
o Poor geographical distribution of services with the majority of services concentrated in
Kitchener-Waterloo

There were also several barriers to accessing trauma services. These were:
o Social and financial challenges experienced by low income service users
o Cultural barriers to services - including language barriers to newcomers to Canada
o Stigma from the association between counselling and mental illness

Recommendations
In order to address the gaps and barriers identified in the service system, the following were
recommended:
1. Enhance the capacity for trauma counselling and treatment by increasing the number of
counsellors and therapists who are trained in new techniques for trauma treatment
2. Promote trauma-informed practice among support service agencies through trauma-awareness
training and the development and adoption of a common protocol for trauma-informed practice
3. Improve inter-agency communication by enhancing information sharing and building referral
relationships between trauma treatment services and support service agencies
4. Increase access to services for all populations through better coordination of services and
providing services at central locations
5. Develop culturally appropriate trauma services by increasing cultural awareness and promoting
cultural diversity among staff
6. Raise awareness about trauma and trauma services among community members through
outreach and public education
7. Develop a region-specific action plan for trauma services that specifies outcomes with
measurable indicators of change
8. Increase funding for trauma services in the region through advocacy and inter-agency
collaboration for funding

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Introduction and Background
In November 2011, the AIDS Committee of Kitchener-Waterloo Cambridge and Area (ACCKWA), K-W
Multi-Cultural Centre (KWMC), Sanguen Health Centre (SHC), the Centre for Community Based Research
(CCBR) and Mosaic Counselling Services held a series of meetings to discuss the need for accessible
trauma services in the Region of Waterloo. The meetings were convened because service providers in
the region were becoming increasingly aware that many of their clients were dealing with trauma, and
were concerned about the lack of access to trauma treatment for them. The initial group of five was
later joined by the Waterloo Region Coalition on Trauma-Informed Services, the Self-Help Alliance, and
Healing of the Seven Generations representing Waterloo Region Aboriginal service providers.

The group identified the following client groups as needing trauma services but lack access: new
immigrants and refugees escaping war and conflict, individuals faced with life-threatening disease such
as HIV/AIDS or the Hepatitis C, people who are homeless, people who are living with mental illness,
Aboriginal people who are dealing with inter-generational trauma, and members of the Lesbian, Gay,
Bisexual, Transgendered, and Queer (LGBTQ) community.

In response to the need identified above, the group started this initiative to explore the need for
inclusive, accessible and appropriate trauma services in the Region of Waterloo and identify solutions.
The main objectives of the initiative were:

o To mobilize stakeholders towards enhancing capacity for inclusive, accessible and appropriate
trauma services in the Region of Waterloo
o To understand trauma service needs of affected populations in the region
o To document existing trauma services in the Region of Waterloo
o To identify gaps and barriers to trauma services
o To initiate an action plan for addressing the gaps and barriers identified

To achieve these objectives, the group developed a project with three main components: 1) community
engagement, 2) needs assessment, and 3) action planning. It then constituted itself into the Waterloo
Region Trauma Service Initiative and submitted a funding proposal to the Ontario Trillium Foundation
(OTF). The project received OTF funding from July 2012 to October 2013.

Psychological or emotional trauma

The focus of the Waterloo Region Trauma Service Initiative is psychological or emotional trauma.
Trauma is psychological or emotional shock that produces disordered feelings or behaviour in a person
(see Taber’s Medical Dictionary). The Diagnostic and Statistical Manual (DSM-IV) defines it as “an
experience of an event that involves actual or threatened death or serious injury, or other threat to
one’s physical integrity; or witnessing an event that involves death, injury, or a threat to the physical
integrity of another person; or learning about unexpected or violent death, serious harm, or threat of
death or injury experienced by a family member or other close associate” (p. 424) (see also DSM V). The
DSM IV definition of trauma emphasizes the experience of a traumatic event; other definitions,
however, emphasize both the experience of an event and its resulting negative effects on personal

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functioning. For instance, Hemmert and Oberdier (2007) defined trauma as an experience that is
emotionally so painful, distressful or shocking that it produces lasting negative effects on the individual’s
mental, physical, social or emotional functioning (see also, NCTIC, 2012).

Trauma includes responses to powerful one-time incidents such as; serious accidents, natural disaster,
rape, crime, or diagnosis with a life threatening disease as well as responses to chronic or repetitive
experiences such as abuse, neglect, deprivation, torture, exposure to war and conflict (NCTIC, 2012).
Exposure to traumatic events is, therefore, very common in human society.

In the Adverse Childhood Exposure (ACE) study, Feliti, Anda, Nordenberg and Williamson, (1998)
investigated the impact of Adverse Childhood Exposure (ACEs) to traumatic events on adult life. The
study explored the effects of three categories of abuse (emotional, physical & sexual), two categories of
neglect (emotional & physical) and five categories of household dysfunction (mother treated violently,
household substance abuse, household mental illness, parental separation or divorce & incarcerated
household member). Two-thirds of the 17,337 participants reported exposure to at least one ACE
category, and more than one-fifth reported three or more categories. Also, Whaley (2009) noted that
between 5 and 40% of survivors of serious natural or man-made disasters suffer from trauma.
Consistent with Whaley’s (2009) range, Kessler, Galea, Gruber and Sampson (2008) found that 25% of
people in a sample from New Orleans met the criteria for PTSD after Hurricane Katrina. Also, the
National Center for PTSD1 found that 23% of survivors of the Oklahoma City bombing in 1995 suffered
depression.

Trauma has a devastating effect on an individual’s life. Traumatic events elicit intense fear, helplessness
or horror, and depending upon the strength or persistence of these responses, they may trigger three
clusters of PTSD symptoms: 1) re-experiencing the trauma through nightmares, flashbacks or intrusive
thoughts; 2) persistent avoidance of reminders of the incident including avoidance of similar situations
and numbing of general responsiveness; or 3) persistent increased arousal such as experiencing sleep
difficulties, hyper vigilance, or irritability (NCTIC, 2012). According to NCTIC, these symptoms cause
clinically significant distress or impairment in social, occupational, or other important areas of
functioning. This assertion is supported by the Canadian Centre on Substance Abuse which states that
trauma interferes with a person’s sense of safety, self and self-efficacy, and also interferes with one’s
ability to regulate emotions and navigate relationships (CCSA, 2012).

Consistent with the above assertion, the ACE study found a graded relationship between the number of
ACEs reported and various health risk behaviours and diseases. Compared to people without any
childhood exposure, individuals reporting four or more ACEs were more likely to report alcoholism, drug
abuse, depression, and suicide attempts. They were also more likely to report smoking poor self-rated
health, multiple (50+) sexual partners, sexually transmitted diseases, physical inactivity and obesity. The
study also found a graded relationship between the number ACEs reported and ischemic heart disease,
cancer, chronic lung disease, skeletal fractures, liver disease, victimization of rape and predisposition to
domestic violence (Feliti et al., 1998). Furthermore, the study found a strong association between ACEs

1
http://www.ptsd.va.gov/

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and premature mortality. Out of a final sample of 17,337 participants, 1,539 died during a follow up
period of about 10 years. Analysis of the data on those who died showed that people who reported six
or more ACEs died 20 years earlier than those who reported no ACEs (Brown, Ander, Tiemeier & Feliti,
2009).

Other studies have also shown a strong relationship between trauma and severe mental illness (SMI)
(Harris, 2003; Mueser, Goodman, Trumbetta & Rosenberg, 1998) and substance use disorders
(Rosenberg, Mueser, Friedman & Gorman, 2001; Stewart, 1996; Stewart, Pihl, Conrod, & Dongier, 1998).
Among people with severe mental illness, trauma is also known to be associated with severe symptoms
and negative treatment outcomes, leading to multiple hospitalizations and use of more costly
psychiatric services (Harris, 2003).

Despite the known associations between trauma and mental illness and substance abuse problems,
trauma is typically not treated in people using mental health services (Wiechelt, Delprino & Swarthout,
2009). According to Harris (2003), when not treated, trauma has the potential to interfere with
treatment of other conditions. Service providers who are involved in this study shared Harris’ (2003)
point of view. They expressed that, treating the underlying trauma in many clients would not only
improve the effectiveness of their agencies’ services but would also enhance treatment of clients’
primary presenting issues. However, in most cases, their clients do not have access to trauma
treatment; hence the need for a comprehensive response to trauma in the Region of Waterloo.

Response to trauma in Canada and the United States

An increase in awareness of the prevalence and impact of trauma has led to several trauma response
initiatives in both the United States and Canada in the last decade. In 2000, the U.S. Congress
established the National Child Traumatic Stress Network2 (NCTSN) as part of the Children’s Health Act
for the purpose of developing effective models of treatment and providing supports for service
providers. Since its inception, the NCTSN has established and coordinates a collaborative network of
over 150 centres located in universities, hospitals and community-based organizations. The NCTSN
supports the development of evidence-based treatments and promising practices for traumatized
children and their families. In 2001, 12 states in the U.S. came together to form the State Public Systems
Coalition on Trauma (SPSCOT), an informal network for sharing ideas on developing trauma-informed
systems of care (see Jennings, 2007). By 2004 the number of states involved in SPSCOT had increased to
31. SPSCOT works with stakeholders including mental health policy makers, senior staff of mental health
agencies and mental health service users to develop common criteria for building trauma-informed
mental health service systems (Jennings, 2007). Also, in 2005, the Substance Abuse and Mental Health
Services Administration (SAMHSA) created the National Center for Trauma-Informed Care3 (NCTIC), a
technical assistance centre that supports the development of trauma-informed care in publicly funded
health care systems.

2
http://www.nctsn.org/about-us/history-of-the-nctsn
3
http://www.samhsa.gov/nctic/

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Besides the national initiatives above, there are several state and city level trauma initiatives in the U.S.
These include the Connecticut Department of Mental Health and Addictions Services’ Trauma Initiative4,
which focuses on the delivery of behavioural care in a way that is sensitive and responsive to the needs
of people who are affected by trauma; the Pennsylvania’s Department of Behavioral Health and
Intellectual Disability Services5 (DBHIDS) trauma initiative, which emphasizes creating a more trauma-
informed system of care for men and women who have been affected by trauma; and the South
Carolina Trauma Initiative whose goals are to sensitize stakeholders to the impact of trauma, influence
policies, educate and train clinicians, address concerns about the safety and dignity of psychiatric
settings, and increase knowledge by supporting a strong empirical research platform (Cusack, Wells,
Grubaugh & Hiers, 2007). An example of a city level trauma initiative is the Chaddock Trauma Initiative6
(CTI; a member of NCTSN) of Quincy, Illinois. CTI focuses on providing specialized trauma treatment
services to children and adolescents who have experienced at least one type of trauma.

In Canada, the most acclaimed trauma service initiative is the Manitoba Trauma Partnership (MTP). The
MTP promotes and supports trauma-informed practice in Manitoba through advocacy for common
approaches to clinical consultation, research, mental health promotion, complementary care, trauma
recovery, and raising public awareness. Furthermore, the MTP provides training and education,
promotes knowledge exchange, transfer and translation, and supports the enhancement of local
capacity for trauma treatment and trauma-informed services. In furtherance of its goal of greater public
awareness about trauma, the MTP has established the Manitoba Trauma Information and Education
Centre7 (MTIEC), which identifies and promotes standards and guidelines for trauma-informed care as
well as research and evaluation (Proulx, 2009).

Other trauma service initiatives in Canada include the British Columbia Centre of Excellence for
Women’s Health’s (BCCEWH) project: Coalescing on Women and Substance Use: Linking Research,
Practice and Policy8, which facilitates virtual discussions about substance use-related trauma among
women, and trauma in treatment settings; a recent initiative by the Centre for Addiction and Mental
Health (CAMH) that led to the publication of a volume titled Becoming Trauma-Informed. This resource
describes trauma-informed practice at the individual, organizational and systemic levels (see Poole &
Greaves (2012); and the Program for Traumatic Stress Recovery (PTSR) by Homewood Hospital (Guelph,
Ontario) (see Wright & Woo, 2000). The Program for Traumatic Stress Recovery is a specialized inpatient
treatment for adults suffering from PTSD.

In the region of Waterloo (Ontario), there are a few ongoing initiatives promoting trauma-informed
practice. For example, Trellis Mental Health and Developmental Services (now amalgamated with
Canadian Mental Health Association) provides trauma-informed training to agencies in the Region of
Waterloo and Guelph-Wellington-Dufferin. The Waterloo Region Coalition on Trauma-Informed Services
(formerly known as the Trauma Table) promotes trauma-informed practice among community service

4
http://www.ct.gov/DMHAS/cwp/view.asp?a=2901&q=335292
5
http://dbhids.org/trauma-initiative/
6
http://www.chaddock.org/professionals/trauma-initiative
7
http://trauma-informed.ca/trauma-informed-organizationssystems/becoming-trauma-informed/
8
http:/bccewh.bc.ca/bccewh-initiatives/coalescing-on-women-and-substance-use.htm

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agencies. Also, the Healing of the Seven Generations provides cultural ceremonies for Aboriginal people
who are dealing with trauma.

The main purpose of trauma-response initiatives is to build trauma-informed systems of care. Trauma-
informed systems of care are integrated and comprehensive systems that incorporate evidence-based
trauma treatment and trauma-informed services. Trauma response initiatives work with trauma-specific
services towards raising standard of care and improving access to services for trauma survivors, and
their families and communities. They also work with community service agencies towards adopting
trauma-informed practice (Harris & Fallot, 2001).

Trauma-specific services are services that are designed to treat trauma (Harris & Fallot, 2001). They
provide counselling/therapy to help trauma survivors to recover and heal. More specifically, trauma-
specific services include grounding techniques, which help trauma survivors to manage dissociative
symptoms; desensitization therapies, which help to render painful images more tolerable; and
behavioral therapies, which teach skills for the modulation of powerful emotions (Harris & Fallot, 2001).
Trauma response initiatives promote the development and adoption of treatment models that are
based on scientific, clinical, and culturally relevant data by trauma-specific services.

Trauma-informed practice, on the other hand, is a term used to describe services that are designed to
accommodate the vulnerabilities of trauma survivors (Harris & Fallot, 2001; Jennings; 2008). It refers to
an approach to service delivery that makes services welcoming, appropriate and empowering to trauma
survivors reducing the likelihood of re-traumatization. According to Jennings (2008), trauma-informed
services are services that are informed about, and sensitive to trauma-related issues present in
survivors.

Trauma-informed services identify and validate the strengths of trauma survivors and support them to
build new coping skills (Harris & Fallot, 2001). Furthermore, they provide their staff with knowledge
about trauma and how it affects people, and train them in new ways to assist clients. They also train
staff to understand the service system and how to link people to appropriate services and supports.
Trauma-informed services build collaborative relationships with public sector service systems as well as
with practitioners and clinicians with expertise in trauma
Steps for a Trauma-Informed System
recovery to ensure that people receive adequate and
Administrative commitment to change
appropriate care. These services incorporate the core values
of safety, trustworthiness, choice, collaboration, full 
participation and empowerment in all aspects of service Universal screening
planning and delivery (see also Jennings; 2008). 
Training and education
Harris and Fallot (2001) outlined five concrete steps for 
implementing a trauma-informed system of care. These are: Informed hiring practices
1) Administrative commitment for change which requires 
conscious effort by those who control resources within Review of policies and procedures
an organization to commit to integrating knowledge
about trauma into service delivery

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2) Universal Screening for trauma by all human service organizations regardless of their missions
3) Introductory Training and Education about trauma for all staff
4) Informed Hiring Practices by organizations to ensure that new employees have a basic
understanding of trauma
5) Review of Policies and Procedures to ensure that they are not harmful to clients

Models of service delivery

As part of this project, several models of service delivery in health care systems were reviewed to inform
action planning. Summaries of two comprehensive models are presented below for consideration
towards developing a trauma-informed system of care in the Region of Waterloo.

The hub model: The first comprehensive model of service delivery is called a service hub. A service hub
is a diverse collection of heterogeneous services, capable of meeting the myriad set of client needs,
organized around a central entity (the hub) that maintains the course or direction of collaboration. Like
the wheel of a bicycle, the hub is an integral part of the service system but has the central role of
directing consumers and resources to appropriate services within the system, and also steering policy
development (Dear, Wolch & Wilton, 1994).

The strength of this model is that it provides a highly functional and supportive service environment that
builds on the collective capacity of participating agencies. Furthermore, participating agencies and
services are able to act as a united holistic system through the coordinating entity without the
requirement of additional coordinating resources. The hub can also be flexible to the available resources
in a given location owing to its adaptability as a guiding organization: the hub may expand as services
expand or contract as services contract (Dear, Wolch & Wilton, 1994).

The hub model has been implemented effectively in a number of health service systems. For instance,
the Canadian Mental Health Association (CMHA), Winnipeg Region operates an Information and Referral
Service as a hub that provides knowledge of services and supports for people experiencing mental
health problems (Kaplan, 2008). The program targets four types of clients:

 Mental health care consumers who are aware of their areas of need
 Mental health care consumers needing services who are unaware of what is needed
 Individuals needing assistance regarding legal, therapeutic, and social entitlements
 Consumers, service providers, or family members needing consultation and support

The CMHA Winnipeg Region Information and Referral Service initiative was reviewed in a recent
evaluation completed by an external service. Through the first four years of operation the service
provided information and referral to more than 9000 contacts. The evaluation revealed that 68.2% of
the contacts led to a referral to a range of services, including legal aid, mental health advocates,
rehabilitation services, mental health associations, counseling, and crisis services. Nearly all participants
in the evaluation (93.6%) reported satisfaction with services (Kaplan, 2008).

There are some limitations to the effectiveness of the hub model. These are often related to the nature
of the central entity, which may include the following:

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  Funding: While flexible, some form of core funding is required to maintain the central entity.
This often poses a challenge to establishing the hub.
 Steering: The organizational direction of the hub may conflict with that of one or more
participating agencies in areas such as policy, referrals, and distribution of funding. This may
affect agency buy-in.
 Maintaining client engagement: Some hubs run the risk of establishing a power imbalance that
overlooks the needs and priorities of the community being served. This is particularly relevant in
hubs that are overly-professionalized.
 Scope and geography: Hubs may not be able to adequately address large geographic areas (for
instance in the Region of Waterloo), due to the centralized design.

(see Lafrenière, 2013)

The network model: The second comprehensive model of service delivery is the network model. This
model takes a “no door is the wrong door” approach to service provision. It relies on effective
partnership and communication among all agencies in the service system. In this model, consumers can
gain access and/or referrals to services at any of the organizations within the network. The process is
streamlined through the use of standardized screening tools and a comprehensive directory of services.
Leadership is provided to the group through an advisory/leadership group that is representative of all
agencies (Alter, 1990).

The greatest asset of the network model of service delivery is increased accessibility to services. Like the
hub model, the network model makes use of the collective capacities of partnering organizations to
improve services. However, rather than relying on a central entity for guidance, networks are an
integrated set of self-directed organizations. The level of integration is flexible according to the
community’s needs and can range from information sharing to systems integration (Provan & Sebastian,
1998).

A number of communities in Canada have implemented this model of service delivery. For instance, the
Sexual Assault Response Team (SART) of Waterloo Region is an established collaborative partnership of
organizations providing sexual assault support services to victims-survivors and offenders. More than 18
support agencies are involved, and have made statements of commitment to a shared set of principles,
values, and beliefs, along with treatment and response procedures.

A second example of the network model in action is the Manitoba Trauma Partnership (MTP). The MTP,
as described earlier is designed to promote information sharing and improve local capacity for trauma
treatment and trauma-informed services using an integrated approach.

The network model is reliant on a less formalized partnership of agencies; as a result it faces several
challenges to its success:

 Funding: Like the hub model, funding presents a significant challenge to the network model.
Resources are required to ensure that all participating agencies are meeting common standards,
and are retrained where needed.

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 Over-reaching: There is some evidence that networks become less effective as they grow larger
and/or attempt to cover large geographical areas due to breakdowns in communication and
familiarity. This is especially true about diverse service agencies.
 Conflict and maintenance: There is also a risk that conflict between organizations may arise
from unequal distribution of resources. This is particularly relevant in situations where there is
greater differentiation by function and service.
 Maintaining momentum: As a less formal arrangement, networks and their guiding
organizations are tasked with maintaining interest in communality among service providers. This
is not always easy as agencies’ interests and focus shift to new issues and challenges.

(see Alter, 1990; Provan & Sebastian, 1998)

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Overview of the Needs Assessment
This section of the report outlines the purpose of the needs assessment, its design, approach and
methods.

Purpose
The purpose of the needs assessment was: 1) To understand trauma service needs in the Region of
Waterloo; 2) To document existing trauma services in the region; 3) To identify gaps and barriers to
trauma services; and 4) To find ways to address the gaps and barriers.

Needs assessment questions

The needs assessment was guided by five main questions:
1. Which populations are affected by trauma?
2. What trauma services exist in the Region of Waterloo?
3. What are the gaps in trauma services?
4. What are the barriers to accessing trauma services?
5. How can the gaps and barriers be addressed?

Approach and design

Approach: A participatory research approach was used for this needs assessment. Accordingly, a project
steering committee of stakeholders guided the process. The steering committee reviewed all data
gathering instruments as well as recruitment strategies and provided feedback on them.

Design: A mixed methods design was utilized in the needs assessment. Accordingly, data gathering and
analysis involved the use of both quantitative and qualitative methods: these were document review,
focus group interviews and a survey.

Participants
Altogether, 77 people participated in the needs assessment. They were all adults (18 years and older).
Thirty-two of them participated in focus groups and 45 responded to the agency survey.

Participants in the focus groups were service users (n=5), settlement/outreach workers (n=6), members
of the LGBTQ community (n=7), trauma treatment service providers (n=8), and support service providers
(n=6). They included nine males, twenty females and three who described themselves as transgendered
or queer.

The majority (66.6%) of agencies that completed the survey were located in the Cities of Kitchener and
Waterloo. The rest were located in Cambridge, Ayr, Fergus, St. Agatha, Elmira, New Hamburg, North
Dumfries, and St. Jacobs. There were also two agencies that were located outside the Region of
Waterloo (i.e. Guelph). Chart 1 represents the geographical distribution of participating agencies.

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 Chart 1: Geographical distribution of agencies

60% 53.3%

50%

40%

30%
20.0%
20% 13.3%
11.1%
10%
2.2%

0%
Cambridge Kitchener Waterloo Guelph Other*

*Ayr, Fergus, St. Agatha, Elmira, New Hamburg, North Dumfries, St. Jacobs

Data gathering methods

Document review: Reports and scholarly documents about trauma, trauma services, response to trauma
in other jurisdictions, and service delivery models were reviewed as part of the needs assessment. The
document review provided a context for the needs assessment, informed the types of questions asked,
and provided an understanding of different models of service delivery to inform the development of a
Waterloo Region-specific response to trauma.

Agency survey: An online agency survey was developed and distributed to service agencies in the region.
The purpose of the survey was to collect information about existing trauma and trauma-informed
services, service user needs, gaps in services and barriers to accessing services. Items on the survey
included questions about agency size and location, the types of services provided, clients served, staff,
trauma-awareness, and challenges to providing and receiving services.

The survey was distributed using a list of targeted agencies developed collaboratively by the project
coordinator, steering committee, and research team. The survey was self-administered by a
representative of each participating agency.

Focus groups: Five focus groups were held with the following stakeholder groups: service users,
settlement and outreach workers, members of the LGBTQ community, counselling and mental health
service providers, and support service providers. The support service providers included agencies
serving people who are living with HIV and AIDS, people living with or at risk of Hepatitis C infection,
people who are homeless, and immigrants and refugees.

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The purpose of the focus groups was to obtain in-depth information about trauma service needs in the
Waterloo Region. Focus group participants were asked about their knowledge and experience with
trauma and trauma services, service user needs, gaps in trauma services, barriers to accessing services
as well as insights into how trauma services could be enhanced in the Waterloo Region.

Data analysis
Data from the agency survey was analyzed using SPSS software to develop frequency tables. The
analysis produced descriptive statistics about trauma treatment and support services available in the
Region of Waterloo. The results were further analyzed to identify gaps in services and barriers to
accessing services.

Content analysis was performed on the qualitative data gathered through the focus groups. The data
was processed and themes were developed from it to answer the main needs assessment questions.
The themes were based on triangulation of sources. The findings from the qualitative and quantitative
methods were also triangulated to enhance credibility of the findings.

15
Findings
This section of the report is a presentation of the findings of the needs assessment. These findings are
organized thematically according to the main needs assessment questions.

Populations that are affected by trauma

The findings of the needs assessment indicated that there are many people who are suffering from
trauma and need trauma services in the Region of Waterloo. They include several client groups served
by various community agencies in the region. Some of these client groups are victims of rape, abuse,
neglect, household dysfunction and violence; people who are living with mental illness, addictions, HIV
and AIDS; and people who are experiencing homelessness. They also include individuals who have
experienced childhood trauma, Aboriginal people who are living with historic trauma from the
residential school system; and new immigrants and refugees, especially people who had fled from war
and conflict.

Service providers who participated in the needs assessment estimated between 20 and 40 percent of
their clients are suffering from trauma. Although not all of these estimates were based on trauma
assessment9, the range was consistent with levels of trauma typically found in communities that have
experienced serious natural or man-made disasters (Whaley, 2009).

Both service providers and service users identified a range of sources of trauma for the affected
populations. These included such events as natural or man-made disasters that are generally known to
be associated with trauma as well as subtle but insidious day-to-day events in people’s homes that
systematically traumatize them. In the words of one focus group participant,

“Trauma runs every gamut: sexual, emotional, physical [abuse], terror. The most
damaging is the most subtle; [within] families and households with closed doors.”
Service Users’ Focus Group

More specifically, the participants in the focus groups mentioned histories of verbal, physical,
emotional and sexual abuse, neglect, exposure to war, violence, terrorism, addiction, and
disease as frequent sources of trauma. Some participants also cited hate incidents and
discrimination as major sources of trauma for certain population groups including members of
the LGBTQ community. A member of this community said,

“There have been attacks on pride flags as well as beatings, which don’t become
public. In the workplace there are also subtle oppressions which are continued sources
of trauma for individuals.” LGBTQ Focus Group

Service providers also noted that some of their clients are dealing with multiple and ongoing traumas.
These include clients who are faced with multiple stressors such as violent intimate partners, poor
economic situations, and chronic disease. A focus group participant described the following as an
example of multiple traumas:

9
Some of the estimates were based on informal screening or assessment.

16
 “A woman may be at the shelter because something physical had happened and she
got referred. But then [while in the shelter], she [learns about] the power and control
wheel and then she begins to understand how much abuse she had actually
experienced living with an abusive partner.” Service Providers’ Focus Group

Another type of trauma experienced by people which often goes unnoticed and untreated is vicarious
trauma. This is the type of trauma that usually affects service providers and first responders who come
in close contact with victims.

Trauma services in the Region of Waterloo

The needs assessment revealed a range of services in the Region of Waterloo. This included both trauma
treatment and support services. The participants in the agency survey included 17 agencies that provide
trauma treatment and 28 that provide support services to various client groups. They included agencies
that provide services to all age groups; from children (0-11years) through youth (12-12 years) to adults
(18 years or older). The distribution of the agencies by the age groups served is presented in Table 1.

Table 1: Distribution of agencies by age groups served

Age group Frequency Percentage

Children (0-11yrs) 17 37.0%
Youth (12-17yrs) 23 50.0%
Adult (18yrs or older) 38 82.6%

As evident in the percentages shown in the table, the participants included agencies that serve multiple
age groups.

Agencies providing trauma treatment: Of the 17 agencies that provide trauma treatment, eight conduct
assessment on site; 13 provide counselling; nine provide trauma therapy; and one offers cultural
ceremonies (i.e. Aboriginal healing practices). The distribution of the participating agencies by the
aspects of treatment provided.

Table 2: Distribution of agencies by aspect of treatment

Type Frequency Percentage

Assessment 8 47.1%
Counselling 13 76.5%
Therapy 9 52.9%
Cultural ceremonies 1 5.9%

Of the eight agencies that conduct trauma assessment on site, five use formal assessment tools. The
remaining three do informal assessment (i.e. without tools). One focus group participant explained that
her agency uses a checklist to screen for the symptoms of trauma in place of formal assessment.

The agencies that provide trauma counselling and therapy identified several types of trauma-specific
treatment in practice in the region. These included cognitive behavioural therapy (CBT), family therapy,

17
and Eye Movement Desensitization Reprocessing (EMDR). The distribution of the agencies by type of
treatment is presented in Chart 2.

Chart 2: Distribution of agencies by trauma-specific treatments

76.5%
80%
60% 35.3% 41.2% 41.2%
40%
20% 5.9% 5.9%
0%

By far, the most commonly available treatment for trauma is CBT which is used by 76.5% (n=13) of the
agencies. The least used types of treatment were medication and cultural ceremonies. Seven agencies
indicated that they provide “other” types of trauma treatment. One of them offers narrative therapy but
the rest did not specify the type of treatment.

Half of the agencies that provide trauma treatment reported that they offer a set number of sessions of
counselling/therapy to clients. One agency offers 1-6 sessions per client, four offer 7-12 sessions, and
three offer 12-18 sessions.

The majority of agencies providing trauma treatment serve specific client groups based on their
mandates and funding specifications. At the time of the survey, only three out of the seventeen agencies
indicated that they provided trauma treatment to populations outside their target populations. One
agency that had historically accepted clients outside its target population said it no longer had the
capacity to provide such services.

Also, nine of the 17 agencies indicated that they receive referrals for trauma treatment from other
agencies. All nine indicated that their referral sources were all within the region of Waterloo. Needless
to say, all the nine agencies are mandated to serve specific client groups.

The number of counsellors at agencies providing trauma treatment ranged from 1 to 33, with an
average of seven counsellors per agency. The average number of clients per counsellor per week ranged
from a low of 4 to a high of 30, with an average of 12.5. While these figures may seem adequate, the
average number of counsellors who have been trained in trauma-specific counselling and/or therapy
was only 2.8, with 1.3 employed full-time.

The average wait time for clients seeking trauma treatment was six weeks; however, this figure does not
include wait-times for referrals. According to focus group participants there is a long wait-time for
referrals and generally clients have to wait for up to six months to access appropriate trauma services.

18
Agencies providing support services: Of the 45 agencies that responded to the agency survey, 28 provide
support services to various client groups, many of which are believed to have high levels of trauma
based on their self-reported experiences. These client groups include victims of violence and abuse,
people who are homeless, people who are living with HIV and AIDS, people who are living with or at risk
for Hepatitis C infection, new immigrants and refugees, victims of crime (including children), and
members of the LGBTQ community. These agencies were asked about their practices regarding services
to clients who may be experiencing trauma. Specifically, they were asked about trauma awareness
among their staff, trauma recognition and referrals.

Of 24 agencies that responded to the question about trauma awareness; 58.3% (n= 14) of them provide
trauma-awareness training to direct and/or frontline staff. Eleven agencies reported a total number of
29 staff members who had received trauma-awareness training; an average of 2.6 trained staff per
agency.

Over 40% (n=11) of the support service agencies indicated that they screen clients for trauma; however,
only one uses a formal screening tool. Chart 3 represents the distribution of support service agencies
that conduct some form of trauma screening.

Chart 3: Does your agency conduct trauma screening?

Don't know
8% Yes
42%

No
50%

When asked whether they refer clients to trauma treatment, only 37% (n= 10) of the agencies indicated
that they did. Those who did not refer clients for trauma treatment either said they did not have the
resources for referrals or they did not know where to refer clients.

Gaps in trauma services

Further analysis of the data gathered in the needs assessment revealed several gaps and inadequacies
within the system. These included gaps pertaining to agency capacity, resources, knowledge and skills.

Gaps in trauma treatment services: The findings of the needs assessment revealed a lack of capacity for
trauma treatment in the Region of Waterloo. The information gathered indicated that there is an
inadequate number of counsellors who are specifically trained in trauma treatment in the system. Data
provided by 47% (n=8) of the agencies that treat trauma showed that they treated a total of 823 people

19
for trauma in 2012; an average of 102 people per agency for the 12-month period. Yet, as noted earlier
in this report, the average number of counsellors trained in trauma-specific counselling/therapy was
only 2.8 per agency of whom only one was employed full-time. Speaking to the lack of capacity for
trauma treatment, some focus group participants echoed the issue of inadequate number of trained
counsellors for trauma treatment as a persistent gap. According to a focus group participant,

“We don’t have the resources that are needed to have a clinician on staff who can do
the trauma specific stuff. Most of our clinical staff do supportive counselling. Our
trauma specific counsellors are booked up for 6 months. All of our counsellors are
booked for 6 months.” Service Providers' Focus Group.

Furthermore, the survey data showed that only six out of the 17 counselling agencies had a counsellor
who was trained in EMDR, which is considered one of the most current and very effective treatments
available. This finding indicated that although there are many people who need trauma services, the
number of people already accessing these services was already very high considering the number of
counsellors available who are trained in trauma counselling/therapy.

The fact that people in treatment are assigned a limited number of counselling sessions also highlights
the lack of capacity in trauma services. According to focus group participants, once those sessions are
exhausted, the counselling is over. Data from the agency survey indicated that, on average, agencies in
the Waterloo Region offer 6-8 counselling sessions per client. However, some focus group participants
expressed that such limited number of sessions is usually not effective for trauma treatment, especially
for people who experience difficulty in establishing rapport with a counsellor.

“For most people the counselling is difficult to accept – they feel like the counsellor doesn’t
connect with them.” Outreach/Settlement Workers’ Focus Group

According to the focus group participant cited above, by the time some clients begin to feel comfortable
with their counsellor, and are ready to tell their stories, the counselling is over. Such clients end up
leaving treatment in frustration.

Many focus group participants also noted that existing approaches to trauma treatment often overlooks
other client needs such as housing, income, and addiction supports. They explained that when service
users lack certain basic needs, they are less likely to pursue treatment or stay in treatment. Those focus
group participants advocated for a holistic approach to meeting service user needs.

Another serious gap identified in trauma services was related to trauma assessment. The fact that only
eight out of 17 trauma treatment agencies conduct some form of assessment raises a concern that some
people who do not really need treatment may end up being treated. One focus group participant said
his/her agency assumes that all clients who walk through its doors are traumatized:

“It’s fair to say that everyone we deal with is usual working through some sort of [traumatic
experience].” Service Providers’ Focus Group

Another service provider echoed this sentiment by saying:

20
 “All people we treat, they have trauma when they come here.” Service Providers’ Focus Group

Trauma treatment based on such assumptions ignores the fact only up to 40% of individuals who are
exposed to traumatic experiences actually become traumatized. Not conducting assessment before
commencing with trauma treatment could create inefficiencies within the system tying down resources
that could be utilized for people who actually need treatment.

Furthermore, only five agencies that conduct trauma assessment reported using a formal tool. Even
among this group, there was a lack of consistency in the type of tools used. This affects the ability to
gather consistent data on trauma for evaluation purposes. In fact, efforts by the researchers to gather
data on trauma assessment results from participating agencies proved difficult as those agencies that
gather data do so in different formats to meet their reporting requirements.

Gaps in support services: The needs assessment revealed several gaps in support services in relation to
their ability to recognize trauma, work with clients in ways that prevent re-traumatization, and connect
them with treatment agencies.

One main gap identified was a lack of awareness and understanding of trauma among service
providers. Responses to the agency survey revealed that the majority of support service agencies are
not trauma-informed. Most agencies do not have policies and strategies geared towards becoming
trauma-informed. For example, more than half of the 28 agencies offering support services do not
provide trauma-informed training to their staff. Even among those agencies that said they provide
trauma-informed training to staff, very few staff members have received training to recognize trauma
and deliver services in appropriate ways to avoid re-traumatizing clients. In the words of one focus
group participant,

“We have gaps. From a literacy standpoint I don’t think that we understand, as an
organization, what trauma is. People (on staff) might identify the big T traumas, but don’t
even think about the “little t’s” that happen on a daily basis.” Service Providers’ Focus
Group

The result of agencies’ lack of trauma-informed training is not lost on service users. Participants in the
outreach/settlement workers’ focus group expressed that service users often get frustrated because
they feel their needs are not being met.

“You want to feel safe. You want to feel like someone is listening to you. It’s harder because you
are such an emotional wreck.” Outreach/Settlement Workers Focus Group

The needs assessment also revealed gaps in communication about trauma services among agencies,
especially between trauma treatment and support service agencies. Many focus group participants
recounted challenges that they had faced in finding information about agencies providing trauma
treatment. Several service users explained that this often results in being “bounced around” between
agencies until adequate services were located. Some focus group participants lamented the fact that
sometimes agencies work in silos, each not knowing what other agencies are doing.

21
Related to the lack of communication is a lack of referral relationships between trauma treatment
agencies and support service agencies. Some support service agencies, for example, were aware of
trauma-related services at other agencies within the region but did not have any referral relationships
with them. This makes it difficult for them to connect clients to trauma treatment services.

Barriers to accessing trauma services

Participants in the needs assessment identified several barriers to accessing trauma treatment from the
perspectives of both service providers and service users. These barriers are presented below.

Service barriers: One of the main barriers to services identified was limited availability of services,
which reduces access to services for service users. Service providers identified three main factors that
are responsible for the lack of access to trauma services in the Region of Waterloo. They are:

i) Limited availability of resources: According to participants in the service providers’ focus group,
many agencies do not have sufficient funding for staffing and services. The result is usually a
cap on the number of counselling/therapy sessions offered to clients, irrespective of their
needs. Additionally, strict mandates and funding specifications further reduce access to trauma
treatment. Agencies that are mandated to serve specific client groups are sometimes limited in
their ability to provide services to people outside their target populations.
ii) Long wait-times: Long wait-times created by the limited number of counsellors were also
identified as a significant barrier to accessing trauma services: 34% of agency survey participants
(n-11) identified long wait-times as a barrier to services. This assertion was also supported by
focus group participants who attributed this partly to the inadequate numbers of counsellors in
the system.

“I sit on both sides of the fence with this because we have trauma-specific trained clinicians (e.g.
EMDR, trauma-focused CBT, EFT) but there’s not enough of us and [so] there’s a long waitlist.”
Service Providers’ Focus Group

iii) Lack of cultural competency and cultural awareness: Lack of cultural competency and cultural
awareness among staff at both trauma treatment and support service agencies were identified
as another barrier. Focus group participants noted that staffing, especially within the
professional ranks at service agencies, does not reflect the demographics of the region. As such
many service providers have limited awareness of different cultural world views and their
implications to service delivery. In the words of one focus group participant,

“There is a lack of counsellors and doctors who speak different languages or have first-hand
knowledge of cultural and religious issues [regarding] newcomers.” Outreach/Settlement
Workers’ Focus Group)

Focus group participants opined that many agencies lack the knowledge and skills for meeting
the unique needs of such population groups as newcomers, Aboriginal people, seniors and
LGBTQ community. According to some service users, this often results in a lot of frustration for

22
 service users who find it very hard to locate appropriate services. One participant expressed it as
follows:

“There have been hang-ups with the whole process of trying to obtain care.” LGBTQ Focus
Group

Another major barrier to accessing trauma services in the Region of Waterloo is the poor geographical
distribution of services in the region. Focus group participants noted that most of the services available
in the region are concentrated within the cities of Kitchener and Waterloo and this makes it difficult for
people living in other cities and small towns to access them.

Related to the poor geographical distribution of services are the challenges of transportation, travel-
time and travel-cost. According to participants in the focus groups, individuals living in Cambridge and
the rural townships encounter significant barriers in the form of transportation, travel time and
associated costs when seeking services. There are no bus services between Kitchener-Waterloo and
most rural townships in the region. This makes it difficult for individuals living in those townships who
do not have personal means of transportation to access services that are located in the twin-cities of
Kitchener and Waterloo. Even where there is transportation, travel-time and the travel-cost pose
challenges to many service users.

Service user barriers: A major barrier to accessing trauma treatment is the social and financial
challenges experienced by low income service users. For example, focus group participants noted that
individuals who are struggling with unemployment/underemployment are less likely to seek help with
trauma. According to them, more often than not, such individuals lack health coverage or have
inadequate coverage for trauma counselling/therapy and therefore have to pay out-of-pocket.

Related to financial challenges is the cost of services to clients, which was seen as another barrier to
accessing trauma treatment. Although only 15% of agency survey participants (n=5) identified the cost
of services to clients as a barrier, most service users and outreach /settlement workers viewed it as a
very significant barrier. According to those focus group participants, the cost associated with counselling
and treatment was simply unaffordable for many affected people. In the words of one participant,

“Many clients can’t afford counselling.” Outreach/Settlement Workers’ Focus Group

Another major barrier to accessing services was language. More than half of the 32 agencies that
responded to the agency survey identified language as a significant barrier to accessing services
including trauma treatment. The percentages of agency survey participants who identified language and
other factors as barriers to accessing services are presented in Chart 4 below:

23
 Chart 4: Barriers to accessing services

56.3%
60%
46.9%
50%
34.4%
40%
30% 21.9%
15.6%
20% 12.5%
10%
0%
Language Cultural Cost Long wait- Location Other (e.g.
times stigma)

The view point that language was a barrier to services was corroborated by focus group participants
who noted that many newcomers/refugees experience difficulties communicating their health problems
in English which is a second language to them.

Participants in the agency survey and focus groups also identified other cultural barriers to accessing
services in general and trauma treatment in particular. According to some focus group participants,
existing treatment and support services are often framed within a North American context that ignores
other cultural worldviews. This makes it difficult for some services users, especially newcomers and
refugees, to communicate their experiences and symptoms to service providers.

Another major barrier to accessing trauma services was stigma. Some participants in the needs
assessment expressed that people often associate counselling with mental illness and therefore find it
stigmatizing. Also, some participants in the service user and outreach/settlement workers’ focus groups
said that trauma treatment is often pathologized which makes many service users very uncomfortable.
In the words of one service user, the use of the word “treatment” is, in itself, stigmatizing. According to
her,

“’Treating’ means there is something wrong with you.” Service Users’ Focus Group

The perception of stigma also discourages individuals living in small communities from seeking
treatment for trauma. According to some focus group participants, living in small communities erodes
anonymity and this often makes it difficult for many affected people to seek help.

Lack of awareness and understanding of trauma within the population also serves as a barrier to
accessing trauma services. There are many people who are dealing with the symptoms of trauma but do
not understand that they could seek counselling help with it. Participants in the outreach/settlement
workers’ focus group especially spoke about the lack of awareness of trauma among newcomers and
refugees from cultures where support systems are completely unavailable. According to one of the
participants,

24
 “People don’t know – back home there is no system. Clients have a hard time because
it means a gap in faith. One client waited and had to convince herself, ‘If you’re sick,
you go to a doctor’ …” Outreach/Settlement Workers Focus Group

The lack of awareness about trauma does not only affect newcomers and refugees; it cuts across the
population sub-groups that make up the fabric of any community. People who are homeless, people
who are living with HIV and AIDS, and abused spouses usually live with the symptoms of trauma for a
long time without realizing what they are dealing with.

Conclusions and Recommendations

In conclusion, the needs assessment revealed that there are many client groups who need trauma
assessment and treatment in this region. These include victims of rape, abuse, neglect, household
dysfunction and violence; people who are living with mental illness, addictions, HIV and AIDS; people
who are experiencing homelessness; individuals who have experienced childhood traumatic events;
Aboriginal people who are living with historic trauma from the residential school system; and new
immigrants and refugees, especially those from war and conflict zones. There are also service providers
and first responders who are suffering from vicarious trauma.

Although there are some trauma services in the Region of Waterloo, not all the affected client groups
have access to these services. Trauma counselling is usually part of mandated services to such client
groups as victims of crime, rape, sexual abuse and spousal abuse; client groups referred to as
experiencing “Big T” traumas. However, there are many other client groups, including people who are
homeless, people who are living with HIV and AIDS, and people who are living with mental illness or
addictions who are suffering from trauma (“Small t”) but who simply do not have access to trauma
treatment.

There are several gaps and barriers in the service system which reduce access to services to the client
groups identified above. The gaps in services include: lack of capacity, approaches to trauma treatment
that ignore other service user needs, lack of consistency in trauma assessment, and lack of consistent
data gathering for evaluation purposes. Other gaps in services are lack of awareness and understanding
of trauma among service providers, lack of communication among agencies, and lack of referral
relationships between trauma treatment agencies and support service agencies.

The barriers to accessing trauma services include: a lack of access due to limited availability of
resources, lack of capacity in trauma treatment agencies and long wait-times, a lack of cultural
competency among service providers, a lack of knowledge and skills for meeting the unique needs of
some population sub-groups, and a poor geographical distribution of services in the region. Other
barriers pertaining to service users are: the social and financial challenges experienced by low income
service users, language barriers, cultural barriers including a lack of understanding of other cultural
world views, stigma, and a general lack of awareness of trauma in the population.

Based on these findings, eight main recommendations were generated for addressing the gaps and
barriers. These include developing a region-specific action plan for enhancing trauma services and

25
increasing access to them, promoting trauma-informed practice among support service providers, and
educating the population about trauma. These recommendations are detailed below:

Recommendations

1. Enhance the capacity for trauma counselling and treatment: The trauma treatment services
available in the Region of Waterloo should be augmented with a goal of improving capacity and
accessibility. To reach these goals:
o Increase the number of trained counsellors and therapists, especially people trained in
new techniques for trauma treatment
o Increase financial and physical resources for counselling and treatment
o Improve assessment and screening by providing appropriate tools and training for staff
o Extend treatment to people who need it but do not currently have access
o Develop satellite services in small communities

2. Promote trauma-informed practice among agencies: Agencies that provide support services to
various client groups in the region should be aware of trauma, and adopt safe and appropriate
approaches to service delivery for clients who are experiencing trauma. To achieve these goals:
o Provide trauma-awareness training to staff of support service agencies
o Develop a common protocol for trauma-informed practice in the region
o Provide resources to support trauma-informed practice (e.g. web-based resources
including screening tools, and an inventory of trauma services)

3. Improve inter-agency communication: Agencies that make contact with individuals who are
experiencing trauma should have access to information about trauma treatment services and be
able to refer clients to them. In order to achieve these goals:
o Promote information sharing among agencies in the region
o Develop referral relations among agencies (within and across the two sectors: trauma-
specific and trauma-informed services)
o Develop and make available an inventory of trauma services

4. Increase access to services for all populations: Agencies in the region should work together to
remove the barriers to accessing services for all client groups. In order to achieve this goal:
o Provide services at central locations for easy access
o Consider co-location of services to reduce stigma – one-stop-shopping
o Make information about services centrally available to agencies
o Provide better coordination of services for clients, especially people with multiple needs
o Coordinate additional supports for clients (e.g. social, financial, housing, addiction)

26
5. Develop culturally appropriate trauma services: To improve accessibility, trauma services in the
region must be as inclusive as possible for people from all cultures and all walks of life. To
achieve this goal:
o Enhance cultural competency among agencies through cultural awareness training for
staff
o Promote diversity among staff and professionals through training and inclusive hiring
practices
o Increase awareness of personal assumptions about trauma and develop strategies to
overcome them

6. Raise awareness about trauma and trauma services among community members - knowledge is
a primary tool for improving access to services. To achieve this goal:
o Educate community members about trauma and trauma services
o Make information about trauma services readily available to service seekers

7. Develop an action plan for enhancing trauma services in the region. The action plan should:
o Identify a region-specific model for appropriate inclusive and effective services
o Specify outcome objectives with measurable indicators of success
o Develop a system for coherent data collection and evaluation

8. Increase funding for trauma services in the region: Many agencies and services have already
reached their maximum capacity for services based on available resources. Yet the region needs
increased capacity for trauma services. As the capacity to address trauma is directly related to
available funding for services, the following steps are recommended:
o Advocate for funding to increase trauma treatment capacity
o Advocate for funding to implement the action plan for trauma services
o Develop inter-agency collaborations for funding

27
References
Alter, C. (1990). An exploratory study of conflict and coordination in interorganizational service delivery
system. Academy of Management Journal, 33(3), 478-502

American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders IV.
http://www.psychiatry.org/practice/dsm/dsm-iv-tr
Brown, Anda, Tiemeier & Feliti (2009). Adverse Childhood Experiences and the Risk of Premature
Mortality. American Journal of Medicine, 37(5)
CCSA (2012). Essentials of Trauma informed Care. http://www.bccewh.bc.ca/news-
events/documents/PT-Trauma informed-Care-2012-01-en.pdf

Cusack, K.J., Wells, C. B., Grubaugh, A. L., Hiers T. G., Frueh, B. C. (2007). An update on the South
Carolina Trauma Initiative. Psychiatry Services, 58(5):708-10.

Dear, M., Wolch, J., & Wilton, R. (1994). The service hub concept in human services planning. Progress in
Planning, 42, 173-271

Feliti, V. J., Anda, R. F., Nordenberg, D., & Williamson, D. F. (1998). Relationship of Childhood Abuse and
Household Dysfunction to Many of the Leading Causes of Death in Adults. American
Journal of Medicine, 14(4), 245-258
Harris. M. (2003). Modifications in Service Delivery and Clinical Treatment for Women Diagnosed With
Severe Mental Illness Who Are Also the Survivors of Sexual Abuse Trauma. Community
Connections, Washington, DC

Harris, M. & Fallot, R. (2001). Using trauma theory to design service systems: New directions for mental
health services. San Francisco: Jossey-Bass

Hemmert, T. J. & Oberdier, B. A. (2007). Trauma-Informed Treatment in Behavioral Settings. Ohio Legal
Rights Service.

Jennings, A. (2007). Models for developing trauma-informed behavioural health systems and trauma-
specific services: An update of the 2004 report (draft). Retrieved from
http://old.thenationalcouncil.org/galleries/default-file/Jennings%20-
%20Update%20Models%20for%20Developing%20TI%20BH%20Systems.pdf

Jennings, A. (2008). Models for Developing Trauma-Informed Behavioral Health Systems and Trauma-
Specific Services. National Center for Trauma-Informed Care.

Kaplan Research Associates, Inc. (2008). Evaluating selected programs and services of CMHA-Winnipeg:
Study highlights. Retrieved in April 2012 from
http://www.cmhawpg.mb.ca/documents/CMHAEVALUATIONHIGHLIGHTSREPORT2008.
pdf

Kessler, R. C., Galea, S., Gruber, M. J., Sampson, N. A., Ursano, R. J. & Wessely, S. (2008). Trends in
mental illness and suicidality after Hurricane Katrina. Molecular Psychiatry, 13, 374–384.

28
Lafrenière, G. (2013). Brantford neighbourhood hub for prosperity: Report on community conversations
and literature review. Retrieved from
http://www.ourbeststart4brant.ca/files/network/network-
information/innovation/NeighborhoodHub-Report.pdf

National Center for Trauma-Informed Care (2012). Trauma-Informed Services: A new social movement.
http://www.samhsa.gov/nctic/. Brocchure: Retrieved in November 2012
Mueser, K. T., Goodman, L. B., Trumbetta, S. L., Rosenberg, S. D., Osher, F. C. & Vidaver, R. (1998).
Trauma and posttraumatic stress disorder in severe mental illness. Journal of Consulting
and Clinical Psychology, 66, 493–499.
Pennsylvania’s Department of Behavioral Health and Intellectual Disability Services (DBHIDS) Trauma
Initiative. http://dbhids.org/trauma-initiative/

Poole, N. & Greaves, L. (2012). Becoming Trauma-Informed.

http://www.camh.ca/en/education/about/camh_publications/Pages/becoming_trauma
_informed.aspx
Proulx, J. (2009). Planning for a comprehensive trauma recovery system and resource centre in
Manitoba: Summary report of the initial planning day. Retrieved from http://trauma-
informed.ca/traumafiles/trauma%20report%20Jocelyn.pdf

Provan, K. & Sebastian, J. (1998). Networks within networks: Service link overlap, organizational cliques,
and network effectiveness. Academy of Management Journal, 41(4), 453-463

Rosenberg, S. D., Mueser, K. T., Friedman, M. J., Gorman, P. G., Drake, R. E. & Vidaver, R. M. (2001).
Developing effective treatments for posttraumatic disorders among people with severe
mental illness. Psychiatric Services, 52, 1453–1461.

Stewart, S. H. (1996). Alcohol abuse in individuals exposed to trauma: A critical review. Psychological
Bulletin, 120, 83–112.

Stewart, S. H., Pihl, R. O., Conrod, P. J., & Dongier, M. (1998). Functional associations among trauma,
PTSD, and substance-related disorders. Addictive Behaviors, 23, 797–812.

Thornicroft, G. and Tansella, M. (2004). Components of a modern mental health service: A pragmatic
balance of community and hospital care: Overview of systemic evidence. British Journal
of Psychiatry, 185, 283-90

Whaley, A. L. (2009). Trauma Among Survivors of Hurricane Katrina: Considerations and

recommendations for mental health.

Wright, D. C. & Woo, W. L. (2000). Treating Post-Traumatic Stress Disorder in a Therapeutic Community:
The experience of a Canadian Psychiatric Hospital. The International Journal for
Therapeutic and Supportive Organizations 21(2): 105-118. Retrieved in May 2012 from:
http://www.sanctuaryweb.com/PDFs_new/wright_woo.pdf

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