By: Andi Fetzner, LPC, PsyD

In this cartoon by Liz Fosslien, we see two contrasting images that illustrate the impact of conflict. The first shows a tangled ball of yarn between two people—one on the left and one on the right. The individuals’ expressions convey anger and sadness, emotions likely resulting from the stress of the unresolved problem. The caption labels this “unhealthy conflict.” An observer might feel a sense of competition or an urge to be “right” about the solution to the problem—though perhaps I’m projecting.

In the second image, the people are hand-in-hand on the left, while the problem is shown on the right. One person appears to be suggesting a solution, indicated by a speech bubble with an arrow cutting through the tangled yarn. Titled “healthy conflict,” this image aligns with concepts we often discuss in our work promoting a trauma-informed approach.

At Origins, we focus on supporting leaders who cultivate a culture where it’s safe to engage in healthy conflict. When we name and address stress instead of ignoring it, we take away its power. As Brene Brown (2012) notes, “When we bring stress and shame into the light, we diminish their power, as awareness and vulnerability help to counteract their influence.” Similarly, Dan Siegel (2012) reminds us that “we have to name it to tame it.” Relationships are essential in helping us manage stress. Gabor Maté (2019) describes how stress can become toxic when experienced in isolation: “When people experience stress or trauma in isolation, it often becomes toxic, as the absence of supportive relationships exacerbates the impact of adverse events.” Connection, therefore, is foundational to solving problems together.

I recently attended a Roundtable on Relational Coordination (RC) at Berkeley, where practitioners and researchers explored how relationally-based theories, methods, and practices can help address complex challenges—such as equitable healthcare, inclusive education, community well-being, climate change, and even world peace. The event took place the week of the U.S. presidential election, and the theme was “Seeing the Whole Together.” The keynote speaker on day one spoke about finding beauty in the process of our work, likening it to a chorus where each person sings their part within the group to co-create a song. The conference itself mirrored this idea, centered around connection and relationships with dynamic speakers, table discussions, and opportunities for collaboration over two days—a true “chorus” of thought and action.

Rebecca Smith, founder of The Thoughtful Clinician and a nurse midwife specializing in clinical operations, onboarding/training new clinicians, and trauma-informed care, and I were invited to present on integrating trauma-informed care (TIC) at a women’s health center (WHC) within a federally qualified health center (FQHC). Our presentation, titled Using Trauma-Informed Principles to Enhance Relational Coordination in Healthcare Workplace Operations, explored the symbiotic relationship between TIC and RC. We argued that when healthcare workers are better able to regulate their stress and work in a culture that prioritizes connection over being “right,” problems are solved in a more sustainable and efficient way. Simply put, we hypothesized that organizations with a trauma-informed culture see improved outcomes.

Let me provide a few definitions for clarity. Relational coordination is a process of communicating and relating to integrate tasks effectively. It’s shaped by organizational structures and, when strong, supports organizations in achieving desired performance outcomes—including quality, safety, efficiency, well-being, and innovation (Gittell, 2016). RC is particularly important when work is highly interdependent, uncertain, and time-constrained, such as in times of crisis or during everyday stress.

In our presentation, Smith highlighted a common interpretation of trauma-informed care—one focused on patient care. It’s about assuming patients have experienced trauma and providing care that reduces the risk of re-traumatization. She pointed out the incongruity, however, in expecting healthcare workers to provide trauma-informed care while they work within systems that are inherently stressful and often traumatizing themselves—without sufficient prioritization of workforce development and workplace culture. As she put it, “It’s not just about the patients. It’s about us too!”

In our work together at the WHC, we sought to address these barriers. The process began with a workshop that fostered small and large group interactions, where we focused on developing a shared language to discuss stress and resilience. Participants engaged in self-reflection on how stress affects their work and relationships, and we emphasized a strengths-based approach to encourage working smarter, not harder. We also identified a small group of “champions” from various clinic roles to help implement the process. Monthly mindfulness sessions and the application of TIC principles in staff and operations meetings helped reinforce this shift toward relational problem-solving. Four months later, we held a check-in to evaluate the experience, and found that TIC and RC had become intertwined, addressing both the relationships between roles and the humans in those roles.

We were unknowingly practicing many of the principles of RC while implementing TIC in the clinic.

The lesson here is clear: improving outcomes isn’t just about finding the “right” solution—it’s about building and nurturing relationships. Whether we’re addressing a tangled ball of yarn, improving quality improvement (QI) outcomes, or tackling complex systemic challenges, prioritizing connection fosters trust, collaboration, and resilience. When we shift our focus from being “right” to being relational, we create the conditions necessary for lasting solutions and sustainable change. Ultimately, RC and TIC not only support the relationships within organizations, but also provide the foundation for how we work together to overcome even the most daunting challenges.

References:

Brown, B. (2012). Daring greatly: How the courage to be vulnerable transforms the way we live, love, parent, and lead. Gotham Books.

Gittell, J. H. (2016). Transforming relationships for high performance: The power of relational coordination. Stanford University Press.

Siegel, D. J. (2012). The whole-brain child: 12 revolutionary strategies to nurture your child’s developing mind. Bantam Books.

Written by: Andi Fetzner, LPC/PsyD

Fred McFeely Rogers (better known as Mr. Rogers) famously offered the advice during times of trouble: “Look for the helpers. You will always find people who are helping.” Many times throughout my life, I have needed that reminder and have found someone to lighten the weight of the stress of the situation. They didn’t always “fix” the problem but just them being there, listening, and witnessing was invaluable. 

 

Westbrook Health Services in West Virginia has a long history of being a helper in the community. Having started in 1949 by another group of helpers, The Junior League of Parkersburg, they have been serving the Mid-Ohio Valley by providing a broad range of services to support those struggling with their mental health.

 

All helpers at Westbrook including staff, volunteers, and interns complete background checks, a human resource review, and credentials before providing any clinical services. The leaders who support this process are Amanda Cornwell and Olivia Horne, Community Mental Health Trainers and Certified Person-Centered Trauma Informed Care (PCTIC) Trainers. They both participated in a cohort of a train-the-trainer program facilitated by Origins and sponsored by the West Virginia Department of Health and Human Resources in partnership with the West Virginia Health Affairs Institute in Spring 2023. The goal of this program is to help the helpers by training Direct Care Professionals throughout the state on the foundational concepts of PCTIC. 

 

Because the hiring process can vary, training doesn”t always follow the same order for everyone. However, each person eventually learns more about PCTIC and how to apply it in their role within the organization. This approach is less about what the activities are that the helpers are doing and more about how they are doing what they do. This can apply to the administrators and executives, too! “Everyone has Adverse Childhood Experiences (ACEs) and trauma, and it”s like a light bulb goes off when they realize it”s not just about the clients,” Horne explained. During the PCTIC training-of-trainers, one of the activities involved exploring the “why” behind people’s choice of work. Whether they were social service workers, educators, or administrators, the responses were often rooted in a shared motivation: some had received help when they needed it, others hadn’t and now want to be the helper for others or perhaps they saw a need in others and felt driven to fill that role.

The people served by Westbrook face challenges such as addiction and intellectual and developmental disabilities (IDD). As future helpers go through the training, many are surprised to find their own experiences resurfacing, with emotions they “weren’t expecting” being triggered. “Some don’t realize how much this work can affect them,” Horne remarked. Once they reach the PCTIC training, they begin to see common ground. For instance, we all have tough days,” Horne added. Cornwell reported that people also start to recognize, “it might be ME coming in with stress.” 

 

Horne  explained that when people start to understand that client behaviors stem from unmet needs—not an intention to cause trouble, but rather a way of communicating—it transforms how they provide help. She used the example of caring for a newborn: “When you have a newborn, you’re in fight or flight for the first two months of their life. The baby is crying because it needs something—they’re trying to feel safe and secure and are seeking to get their needs met.” This shift in perspective fosters empathy and connection among the helpers, encouraging them to be more gracious and considerate with one another. They also learn to reframe the word “consequence,” moving away from a punitive mindset and instead focusing on addressing the underlying need.

 

Another important lesson Horne and Cornwell have learned as they”ve integrated PCTIC is how the concepts and terms provide a foundation for a shared language among helpers. This common language helps them better understand how to approach their interactions with themselves and others. One example is the Right Response training, which focuses on de-escalation techniques based on universal principles for managing situations safely and skillfully. Cornwell highlighted four key points where these trainings complement each other: first, recognizing that ACEs and trauma are not just present in clients but also in the helpers; second, identifying what a “flipped lid” looks like in oneself and others; third, understanding that helpers need to manage their own emotional state before connecting with others; and fourth, acknowledging that fawning, which can appear as compliance, is often a stress response rooted in fear. Cornwell noted that when these insights were put together, the results were clear: “We got smiles out of it, and everyone understands.”

 

In the interest of broadening the application of a trauma-informed approach to other organizations that serve their clients, Westbrook also received a Mental Health Awareness Training Grant, which allows Horne to offer PCTIC training to the community at no cost. She has been collaborating with various counties, including working alongside the Family Resource Network and Recovery Houses, to support the helpers who serve these communities. By spreading the practice of this approach, the aim is to reduce trauma by increasing the chances that needs will be met for all children and families in the community—whether they are struggling with IDD, addiction, or other challenges. This proactive approach creates a more trauma-informed, compassionate environment that benefits everyone, not just those directly receiving services. By equipping helpers with these tools, Westbrook is fostering a culture of understanding and empathy, making the broader community a more supportive and resilient place for all.

At Origins, we call acting in a way that is trauma-informed humaning. Horne, as a trainer of PCTIC, reported that the simple, but not always easy, practice of integrating mindfulness has made a big difference for her in staying connected. “It’s about taking the time to reflect, breathe, and reconnect with oneself and others, as part of an ongoing commitment to personal growth and effective caregiving.” As the helpers at Westbrook and across the community gain this self-awareness and the practices of PCTIC, they become more attuned to the needs of those they serve and those they work alongside. This can be a lesson for others and we are here to help support you in your journey.

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Written by: Andi Fetzner PsyD

You may have heard the phrase “hurt people hurt people” and thought that it’s just some fluffy way for people to avoid accountability for their actions. But what if this is the foundation for doing just that? When I know I have an injury, I can work to heal it and healed people, heal people.  

 

This is the concept behind the first step in any self-help work. When we know there’s an injury we’ve experienced, we can do something about it. 

In June 2024, I visited an anger management class at Folsom Prison through the invitation by Kara Hunter, a longtime volunteer who has shared her experience and knowledge about conflict resolution through her previous role as Exective Director of Yolo County Resolution Center and continues her work today. We had been invited in December to meet with a group of Veterans but this was going to be different as the men had been going through a curriculum to learn more about anger and how to manage it and many were on the trajectory of thinking about life outside these four walls.

 

My role in meeting with the group was to share information about stress, its impact, and what we can do about it. After walking through the facility, I felt the stress that these men deal with every day. While there were huge trees, sounds of crickets, and deer and turkeys strolling around outside of the prison campus, the sensory experience on the inside consisted of slamming doors, stone walls, and concrete floors. Not to forget the quintessential rooms with bars as doors. The learning center was a different environment. The walls were white and the room was set up like a classroom with desks and chairs. 

 

One thing was clear once we started talking though. The men in this room were living the consequence of how their hurt had impacted others. Some men were in for life, others had decades, and a few could see the light at the end of the literal and proverbial tunnel and were going to be out in society within a matter of months. What they all seemed to have in common was a curiosity of self and a desire to understand why they did what they did and how they could do life differently.

 

We talked about the ACE study. One gentleman asked if there was any hope for people who experienced trauma 0-7 years old. He asked for himself and for his daughter. He was looking for hope. ACEs are not destiny. We shared Dan Siegel’s brain model to describe lid flipping, what happens when we experience toxic levels of stress and we get outside of our connection zone. Another participant made the link between his own behavior and his lid being flipped. He also mentioned that it wasn’t until he started serving time and was offered the stability of food, shelter, and the vocabulary to describe his emotional experience that he started to really be able to take accountability for his actions. We talked about resilience, aka what we can do about it. Mindfulness (noticing the present moment, non-judgmentally), doing the next right thing (controlling what we can and letting go of what we can’t), and sprinkling in this trauma-informed language of resilience-building as a foundation for other programs like 12-step, anger management, parenting classes, and others. When we name it, we can tame it. It’s simple, not easy. We don’t have to do it alone.

Candidly, I felt honored to enter the sacred space of healing in a place that was established to instill a sense of fear as punishment. The leader of the group, Steve, introduced the workshop and provided a capstone at the end to make the link to how anger, one of the many emotions that trauma can create, is part of the flipped lid response system and how building out the connection zone can provide a different pathway for how we interact with one another and with ourselves. The men were insightful, vulnerable, and willing to share and reflect in a unique way. They asked challenging questions, applied the concepts to themselves, and didn’t hesitate to offer gratitude and thanks.  

 

At Origins, we work with people across sectors who are at different places in their journey of healing. We never know what to expect when we enter a room, virtual or in-person. One truth rings loudly for us as we chime the bell in other spaces- we are different leaders when we lead from a healed place than when we lead from a hurt place. Thank you for allowing us to be a part of your journey and for sharing in our journey.

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Defining a trauma-informed approach and figuring out how to put it into action has been a struggle since the inception of the term. At Origins, our answer to this predicament is simple (but not always easy)–a trauma-informed approach is a culture, not a checklist. In other words, this approach is less about what you do and more about how you are doing it. But culture can sometimes feel daunting and nebulous. How can we even get started?

Enter Aaron Scott. Scott is the Northern Training Manager for Burlington United Methodist Family Services, which offers a variety of community-based services, including two residential campuses, recovery support, and targeted case management throughout West Virginia. His experience offers some concrete tips on how to operationalize a trauma-informed culture. His approach speaks to two fundamental components of culture-building: creating a shared language and articulating concrete values.  

 

Scott is a certified Origins facilitator for Person-Centered Trauma-Informed Care (PCTIC). He participated in one of two cohorts of a train-the-trainer program facilitated by Origins and sponsored by the West Virginia Department of Health and Human Services in partnership with the West Virginia Health Affairs Institute in Spring 2023. The goal of this program is to train Direct Care Professionals throughout the state on the foundational concepts of PCTIC. 

 

As part of his role, Scott is in charge of the training program for his agency. His core training program is a 9-10 day training curriculum that uses the PCTIC training as a foundation to establish a shared language and connect the dots among the various other trainings that are offered to staff, including trainings on motivational interviewing and de-escalation. In this model, the PCTIC training is the capstone training that ties together the skills and concepts that have been introduced throughout the training sequence. 

 

Instead of offering a variety of siloed trainings, PCTIC offers an overarching framework  connecting the various trainings. As an example, the de-escalation training introduces the idea of behavior as communication, one of the key concepts of PCTIC. Motivational interviewing establishes collaboration–one of the PCTIC principles–as a key to providing support for people expressing uncertainty about change. 

 

Through this integrated approach, Scott’s overall goal is focused on developing a culture rooted in the values of connection, consistency, and safety. With these values in mind, a key part of building the agency’s culture is about how staff come together and relate to one another during the training. Says Scott, “It’s not about memorization of the materials but application of the principles…there is a soul to this training.” This starts with the culture created within the training environment. 

 

PCTIC helps create connection–both externally with clients and internally among staff. Everyone comes to this work with different life experiences and different stressors. Both of these can affect how we respond in situations. PCTIC encourages us to view the behaviors of others (and our own behavior!) through this lens. Scott noted that this lens has led to an increase in his own patience with others–both inside and outside of the workplace. For example, he says “How do I handle the situation at McDonald’s when my order is running late.”

 

 Working alongside other humans to support other humans (we call this humaning) can help build this culture of connection, consistency, and safety. Says Scott, “This is how we can build an agency’s culture. You can train empathy.”

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More and more organizations are seeing the value of integrating a trauma-informed approach into their organizational culture!

At the 2022 National Association of Community Health Clinic (NACHC) Conference in Chicago, Andi Fetzner, PsyD, and Lori Chelius MBA/MPH presented a poster highlighting Eisner Health’s Journey Through Implementing Trauma Informed Care. It went so well that in 2023, NACHC invited Andi and and the Eisner Team, Deborah Lerner, MD, Dr. Chris Hillson, MD and Gretchen Gates, LCSW from NACHC to host a breakout in San Diego to share best practices and tips to help other community health centers start their own program. We reached 135 people total both virtually and in-person.

Worshop Description: 

How Healthy Is Your Health Center? How to Promote a Trauma Informed Care Environment for Patients and Staff  

This workshop session will provide participants with the opportunity to learn how to create and sustain trauma informed environments for both health center patients and staff. Participants will hear from the Eisner Health team about their trauma informed care implementation journey. Participants will also learn about leadership and frontline staff roles in the implementation process and have hands on experience with tools that can be used every day in a variety of settings.

Some of the audience question/answers included:

How are trauma informed care coordinators funded?

Andi Fetzner – Eisner Health: At Eisner Health, the trauma-informed care coordinator position is a full-time position funded through a HRSA grant. In the first year, they utilized additional funding from a smaller grant to support an external organization to train and coach the internal position on the process of integrating a trauma-informed approach into the organization. State-based or foundation grants can support this approach to include current staff or similar, more part-time positions. Yet another approach other clinics have taken is to have a clinical provider in this role and split their time between patient encounters (billing supports the position) and TIC work (grant-funded).

What is the return on investment? What metrics are you tracking to measure effectiveness of this training?

Andi Fetzner – Eisner Health: The metrics thus far have not been tracked by our QI team but we notice a marked difference in the culture of the organization when people start to use the language of the training in meetings and other interactions. The initial motivation for bringing trauma-informed care into the organization was to decrease escalations. The feedback from staff and managers within the clinics is that the training has given them the language and skills to decrease the impact of stress and increase the ability to connect.

When you train your team members on trauma informed care, do you combine with motivational interviewing techniques or do you keep it separate?

Andi Fetzner – Eisner Health & Gretchen Gates – Enso Integrated Health: The recommendation is to keep these topics separate, especially when first starting to implement trauma-informed care and/or training. When we’re talking about trauma-informed care within a health center or system, we’re talking about culture shift, so it can take some time to build the foundational knowledge and internalize the practices. Even on the clinical side, the goal is to have everyone trained and speaking the language of TIC, as it’s more of a philosophy and way of providing care, while motivational interviewing is more of a discrete technique for clinical interventions.

Since self reflection and self awareness is so central to showing up for others, how can you help improve those skills for yourself and colleagues?

Gretchen Gates – Enso Integrated Health: The best first step can sometimes be just making the time to do it — whether it’s journaling, seeking therapy/counseling, or reading a book on trauma and thinking about its application to my life, I simply have to make the time and prioritize. I think we all are a little afraid to look in the mirror at our pasts, our experiences with trauma, or our biases so it’s easy to avoid. A simple way to start the reflection process is by taking one of the assessments we discussed during the session — either the Professional Quality of Life Scale or Buffalo Self Care Assessment. Either will give you a good idea of what’s going on and where to start to make some changes.

Andi Fetzner – Eisner Health: Past life experiences show up every day in present behavior. Acknowledging this fact helps create a culture where self-reflection and self-awareness are celebrated. While intervening in these moments and debriefing after them is helpful, I find the phrase an ounce of prevention can be worth a pound of cure relevant here. Do things that your future-self will thank you for doing. To me that means saying yes to some things and no to others. Eat breakfast. Ask for help (we have a hard time with this one as helpers). Do something that brings you joy just for fun like wearing a fun nail polish color or your favorite socks. Listen to a song you like. Sing in the car. Go for a walk. Lastly, I am an outdoorsy person and was happy to learn that even having a picture of a mountain or beach or landscape (if you can’t make it out during the day) can help balance one’s mood.

How do you de-stigmatize coping behavior, such as anger, while not enabling actual bad behavior?

Gretchen Gates – Enso Integrated Health: First, I operate under the principle (and share this with others) that everyone is doing the best they can with the knowledge, skills, and information they have at the time. This allows us to see patients and colleagues from a strengths-based and person-first perspective. Second, I view ANY coping, especially coping in the face or history of trauma, as a survival skill. Substance use and abuse, self-harm, running away, anger, pushing others away, overdependence, etc. can all be a learned way to survive an unhealthy situation. When we frame unhealthy coping in this way and provide psychoeducation on trauma and the fight/flight response, I find that people are much more likely to be compassionate with themselves, open to understanding the negative effects of this skill/response, and subsequently be more willing to consider alternative options.

Andi Fetzner – Eisner Health: We get asked this kind of question frequently related to holding people accountable for their actions. I mentioned in the presentation that there is no other approach that allows for people to be as accountable as a trauma-informed approach. As Gretchen mentioned, when a person has the space to understand their emotions, thoughts, and behavior, they can decide whether how they are acting is helpful or not in the current situation. The emotion of anger specifically can be explored and we can understand if there is a frustration, sadness, fear or something else happening. Once a person knows that they are safe to talk about their experience, they can access their whole brain and decide, learn, and think through their actions and reconnect with the team.

Read more about Eisner Health’s journey here: