A chilly gray April day. Standing outside the locked, barred door, pressing the bell. Waiting. What is this place like? What are the people like? Another door. Another set of uncertainties, the unknown.

But what a relief upon stepping inside! Warmth. Comfort. Safety. Pretty things – a giant turquoise glass vessel on a coffee table; wall-sized abstract prints of navy and white, reminiscent of the sea. Cushy soft leather chairs. Fluffy cushions. No hint of “institution” or “facility” here. This could be someone’s living room or a boutique hotel. And then there’s Lisa, who smiles warmly and says, “Hello!”.

How many women, struggling with addiction and the trauma it buffers, have stepped across this threshold and felt the safe, warm embrace of Aventa? How many have left feeling strong and full of hope? Thousands.

Nestled amongst the towering spruce trees of Calgary’s Mission community, the Aventa Centre of Excellence for Women with Addictions has been serving women with addictions for almost 50 years. From its humble roots as a volunteer-run home for women struggling with alcoholism, Aventa has grown and evolved over the years, earning a longstanding and excellent reputation for providing gender-responsive, trauma informed addiction treatment services exclusively to women.

The Aventa Centre of Excellence for Women with Addictions. Photo by Fraser GermAnn, Community Mental Health Action Plan

Today, Aventa has 65 community-based beds and offers three phases of live-in treatment; another live-in program for young adults aged 18-24; an FASD Transitions Program; and a program for pregnant or parenting women with addiction concerns. In addition, Aventa offers a wide array of on-site supports for wellness, and after-care groups to support women in their recovery. [Click here to see a full listing of programs and services.]

Aventa’s mission is: “To improve the lives of women and their families affected by addiction, mental health and trauma through treatment, advocacy and education, in a safe and supportive environment.” Aventa materials often include the statement, “When women are healthy, families are healthy and communities are healthy.”

Capri Rasmussen, Clinical Administrative Manager and Kim Turgeon, Executive Director, Aventa Centre of Excellence for Women with Addictions. Photo courtesy of Aventa.

In 2007, Aventa adopted a gender responsive, trauma informed care (GR-TIC) approach, based on the work of TIC pioneer, Stephanie Covington. Twelve years later, the people at Aventa say that, “trauma informed care is our foundation – it is the core of what we do”.

This story is about what gender responsive TIC (GR-TIC) looks like at Aventa and how the approach has become embedded throughout the organization.

Aventa’s journey to gender-responsive TIC

By the early 2000s, staff at Aventa had long recognized that most of the women they served had experienced trauma at some point in their lives. Trauma was addressed wherever and whenever possible, but many felt there was a need to do more, to make more room for the women’s’ stories of trauma to flow and be heard. There was a receptivity to something better; a readiness for change.

In 2007, a convergence of events and insights further opened the door for that “something better”. There were changes in personnel, Aventa had recently moved into a new facility, a needs assessment determined that Aventa clients would benefit from a trauma-informed curriculum, and Aventa staff heard Stephanie Covington, a leader in TIC, speak at a conference.

Multiple sources of evidence – staff insights and experiences, client experiences, a needs assessment, a consideration of contextual factors, and exploration of research evidence – pointed the way forward. Covington’s holistic and gender-responsive approach seemed a perfect fit. Funding was secured to bring her to Calgary and train Aventa staff, launching Aventa’s journey to gender-responsive TIC, numerous awards, and positive outcomes for the women served by its staff and programs.

What is gender-responsive TIC?

A gender-responsive or gender-specific approach means that TIC is tailored specifically for the gender of people receiving services. This is in recognition that gender-related social roles, relationships, opportunities and identity shape peoples’ experiences and that people of different genders may have different realities and experiences[i]. Specifically, they may experience different forms of trauma and respond to and recover from trauma differently[ii]. It has been demonstrated that addictions in women typically exist for different reasons and manifest differently than for men with addictions. This underlines the need for gender-specific care[iii].

Covington[iv] describes gender-responsive TIC for women this way:

“Being gender responsive means creating an environment through site selection, staff selection, program development, content, and material that reflects an understanding of the realities of the lives of women and girls and that addresses and responds to their strengths and challenges.”

Aventa exclusively serves women, so programs and approaches are tailored to meet their needs. Capri Rasmussen, Clinical Administrative Manager at Aventa says, it’s about, “What’s your experience and how can we better respond to it?”:

“There’s a need to be gender-responsive, culturally responsive – all of those types of things. It doesn’t mean, ‘Not for you’, but it means, ‘What’s your experience and how can we better respond to it?’ It doesn’t mean that men don’t have these types of trauma – we know that they do. But, we’re saying that the women we work with do, so we’re responding to that. We’re serving women… so the programs and approach are customized toward the experiences of women with trauma and addiction…it’s about understanding the lives of women and girls.”

Additional programming to meet the needs of women at Aventa include parenting, female-oriented birth control, sexual abuse counseling and even financial literacy. There is also a strong focus on relationships and helping women to build healthy connections with others.

Some of the materials used in Aventa’s programs. Photo by Fraser GermAnn, Community Mental Health Action Plan.

So, what does GR-TIC look like in practice?

Aventa is an exemplar of how GR-TIC can become integrated into the very fibre of an organization.[v] GR-TIC is not only manifested in the care and services provided; it is also expressed and perpetuated through a web of mutually reinforcing organizational practices and processes – leadership, values and a philosophy of care, roles and responsibilities, hiring practices, training and professional development, policies and procedures, staff wellbeing, monitoring and evaluation, and the physical environment. Below are some examples of these practices and processes.

Interactions and relationships with clients – enacting TIC principles.

TIC principles are enacted in numerous ways. Some examples are listed below.

Trauma awareness. With TIC as the foundation of all its work, Aventa addresses trauma awareness in numerous ways, particularly education for staff (and other agencies as well) that emphasizes how common trauma is, how it impacts people and how they may adapt their behaviours in order to cope and survive.
Emphasis on safety and trustworthiness. Physical safety is ensured in numerous ways, including compliance with established safety guidelines and accreditation criteria. As a residential addiction treatment facility, physical safety is also assured through security features such as locked doors and security cameras.

Psychological safety and trustworthiness are addressed in many ways. A central focus is on building trusting and respectful relationships. While skills and interventions are important, the connection made between two people helps in the change process, as does demonstrating compassion and an understanding that there is a “why” underlying every sort of behaviour.

Transparency is also important. Clients are told what will happen and what to expect in advance. For example, each step of the intake and admission process, and what the treatment program will entail is explained in advance. This helps them to feel safe:

“We’re really good at trying to explain things in advance, what’s going to happen, and that’s part of that safety thing for the clients as well. They’re telling us they want to be here in a safe, sober environment to do their recovery work. They want to make sure we’re providing that to the best of our ability.” [Capri Rasmussen]

The safety of Aventa staff is also important and is addressed through a culture of caring and staff wellbeing (see below).

Opportunities for choice, collaboration and connection – to build a sense of self efficacy, self-determination, dignity and personal control, Aventa emphasizes relational practices that help women build safe and healthy relationships with staff, peers in their program, and with their own families. This is an important part of programming that is offered.

Choices and preferences are accommodated wherever possible and safe. This includes, for example, the ability to practice one’s own religious and cultural traditions:

“We operate from that really neutral space where people are encouraged to bring their experiences or culture, whatever is helpful for them – such as accommodating Ramadan, things like that. That’s part of the consistency and compassion.” [Capri Rasmussen]

Through surveys and evaluations, clients are also asked to suggest improvements to the services that Aventa provides.

Strengths-based, skill building and empowerment – A central aspect of Aventa’s programming is helping women realize that addiction is often a means of coping with trauma – a way of surviving. This helps to build a more positive sense of self which then supports development of new and healthier coping and grounding skills, greater competence, and more broadly, a sense of hope that they can change, and life can look different.

The walls in Aventa’s residential building are covered with inspirational quotes like these. Photos by Fraser GermAnn, Community Mental Health Action Plan.

Organizational conditions and processes

Committed leadership, organizational values and a philosophy of care. Leaders at Aventa are firm believers in, and strong champions of GR-TIC. They are also strong advocates for ongoing learning and quality improvement. A philosophy of care document outlines Aventa’s views on trauma informed care and harm reduction. It talks about the “why”, not just the “what” and includes tips for practice. This leadership and philosophy of care grounds organizational decision making and resource allocations, making GR-TIC a consideration in everything that is done.

Hiring practices. Hiring decisions at Aventa are based on the philosophy: “It’s not about a specific degree; it’s about the best fit”. This is based on research showing that the ability to build a therapeutic alliance is central to success with clients. As such, Aventa looks for people who have a positive attitude, the ability to be welcoming and engaging, who have genuine compassion and unconditional regard for others, and the belief that people (and the sector) can change. These qualities or competencies are then matched with other requirements of the job (e.g., clinical skills, professional designation).

Training and ongoing professional development. Strong emphasis is placed on education for staff. Numerous training and professional development processes are in place, including the following:

Induction training for new clinical staff.
- Completion of components of AHS trauma-informed care modules.
- Completion of online modules developed by Stephanie Covington re: gender-responsive trauma informed care, and clinical care.
- Several weeks of observation and co-facilitation of process groups based on Covington’s material, and then engaging in ongoing clinical supervision with reflective practice on how they’re moving through and integrating the materials into their process groups.
Regular training is offered in three core areas: gender-responsive trauma informed care, addiction, and group counseling. Dr. Covington or her associates have visited Aventa several times to provide training grounded in her GR-TIC research and practice.

Other foundational topics such as ethics, safety, Indigenous awareness and working with diverse communities are addressed annually. Requirements of funders and Accreditation Canada (in order to maintain accredited status) also provide a framework for training content. For example, one funder required that staff to take gender-based analysis training.

Topics of current interest or sector and community issues are also addressed. These topics are identified through conversations with staff as a collective, and individually, and through observation of current issues relating to women with trauma and addiction. Most recently, for example, staff received training related to opioid use.

A half day each month (excluding December and summer) is devoted to training. Staff also take online training. In summer 2019, Aventa staff are trying out some of the online training available through the Crisis and Trauma Resources Institute. They will evaluate these in the fall and decide whether or not to continue with these.

Another component of Aventa’s strong education plan is documentation and manuals. A philosophy of care document guides actions and practices. And, there are manuals that set out organizational practices for specific topics such as ethics, managing information, client confidentiality and so on.
Training for non-clinical staff. Non-clinical staff also receive a general orientation to the women that Aventa serves and why, boundaries and how to support clients. Clinical staff support non-clinical staff in applying this knowledge.
Information about “global topics” as well as community resources and educational opportunities is shared with all staff. For example, for “National Indigenous History Month” and “Indigenous Day”, all staff received an educational email about the Treaty area in which Aventa is situated, community resources and educational opportunities.

Reflective supervision. A core of ongoing practice improvement for clinical staff is clinical supervision – a form of critical reflection. Aventa and has a framework for this that includes three components:

Each clinical staff person reports to a clinically trained program manager who does supervision with them.
A PhD-prepared clinical supervisor provides weekly clinical supervision in a group format. Staff can bring in scenarios or case consults, or there might be discussions about interventions – and what went well, what didn’t go so well. Staff are vulnerable in this kind of process, but it is a safe space and it works, people learn from one another. As Capri Rasmussen notes,

“For every person who has a question, there’s probably three in the audience that didn’t want to ask it that can learn from it. So, we find that group is very helpful because you’re learning in the supervision whether or not you’re the person with the presenting issue. And we’re a team here. So not individuals in private practice; we want to build that team format.”

There is also open supervision time where staff can make one-to-one appointments with the clinical supervisor.

A comfortable meeting space for staff and for clients. Photo by Fraser GermAnn, Community Mental Health Action Plan.

Organizational policies and procedures. Organizational policies and procedures are regularly reviewed to ensure congruence with GR-TIC. Policies, practices and programs that promote healthy connection to children, family members, significant others and the community are an important part of this. This is resonant with the relational base of GR-TIC for women.

Culture of caring and staff wellbeing. Aventa has a staff wellness strategy, and it is recognized that the principles of TIC are also important for staff. The impact of vicarious traumatization for staff is well understood, so supports for prevention and for post-incident are available. Strong emphasis is placed on self-care and “doing your own work” around one’s own traumatic experiences. Alongside that is building a strong and cohesive team. At the core is a culture of respect, caring about the work, caring about each other, having time for training, and having fun together. There are several “Wellness Wednesdays” each year. One of the most recent Wednesday activities was at the luge track at Calgary Olympic Park – a good bonding experience! Others have included meditation workshops and movies. These activities allow staff to get to know each other on a deeper level, strengthening the sense of team. Staff wellbeing surveys are also conducted as part of Aventa’s accreditation with Accreditation Canada.

Ongoing learning and quality improvement. Aventa has strong leadership commitment toward sustaining a culture of ongoing learning and quality improvement. Extensive work around monitoring and evaluation is done. Aventa voluntarily sought and received accreditation from Accreditation Canada in 2011. The organization has “Exemplary Status” from Accreditation Canada. This provides an external validation of the quality of the organization and the care it provides.

[See the story, “Sustaining a culture of continuous learning at the Aventa Centre of Excellence for Women with Addictions” for more information about this [insert link].

A welcoming and safe physical environment. Aventa has taken great care to design physical spaces that are safe, warm and welcoming and feel more like a home than a facility. The buildings are safe, clean, bright and pretty. There are “proper beds” covered with quilts. The walls are covered with art and inspirational quotes. The floors are easy to clean, but they are not “institutional” – they look like a floor you might have in your home. There are nooks and crannies where clients can be alone; and there are communal spaces where they can be together.

Clients have expressed their appreciation of this:

“I hear from a lot of women that talk about when you walk into this place, you feel the care, you feel the welcoming environment… and I hear all the time that Lisa, our receptionist, makes people feel safe and comfortable.” [Capri Rasmussen]

Surveys are done with staff and clients in order to identify what people like about the current environment and what else they would like: “If we could do something different, what would that look like?”. The feedback received has been used to make changes.

Gender-responsive, trauma-specific clinical care

While GR-TIC forms the ground in which all care and services are provided at Aventa, trauma-specific care is also provided by clinical therapists. While anyone can “do” trauma-informed care, trauma specific care requires training and clinical expertise.

For this clinical work, Aventa uses Covington’s model known as “Women’s Integrated Treatment” (WIT). WIT is grounded in theories of addiction, trauma and women’s psychological development. WIT has been shown to result in reduced substance use, less depression and fewer trauma symptoms, including anxiety, sleep disturbances and dissociation[vi].

Specifically, two of Covington’s curricula are used: “Helping Women Recover” and, “Beyond Trauma: A Healing Journey for Women”. These are group process-based and the content is holistic. For example, the content of “Helping Women Recover” focuses on self, relationships, sexuality, and spirituality.

Outcomes

An extensive array of monitoring and evaluation strategies are employed to assess the success of programs and services. The organization produces an annual report of its findings and shares the highlights publicly on its website. From the 2017-2018 report, a sampling of reported outcomes includes:

488 admissions within the reporting period
94% reported having a better understanding of their addiction
97% reported that the treatment program had provided them with skills that are useful for their recovery
93% reported they are better able to manage their emotions
88% reported they are better able to manage their trauma
93% reported feeling better about themselves
97% reported having an increased sense of hope for their future

Clearly, Aventa’s programs and services are generating many beneficial outcomes for the women they serve. Thousands of women have crossed that threshold into Aventa’s embrace, worked with other women and Aventa’s staff, and have found light, love, hope, and strength. This is evidenced not only in the statistics noted above, but in testimonials shared by former clients:

“I came here broken and you helped me pick up the pieces of my life. My future looked bleak and you helped clear the fog in my head. My heart was full of sorrow, but as I leave this place, I am full of light and love. You’ve given me back my life with hope for the future.” [Cathy B., Aventa website]
“The last four and a half months have saved my life. I came to this centre broken and full of self-loathing. I truly believe this program was one of the biggest tools in not only picking up the pieces of myself and my life, but putting them back together in a way that was stronger than I could have ever imagined.” [Ashley F. Aventa website]
“When I came to Aventa I was lost, broken and alone… I was greeted with acceptance and understanding. The program helped me open up, let go and grow in a safe environment. I am leaving Aventa a strong woman, ready to take on the challenges and the future.” [Rachel F. Aventa website]
“Aventa is an awesome program for women suffering from addictions and trauma. I felt like it got more to the root of my problems and why I was drinking so I didn’t have to deal with my feelings. That was what I hadn’t dealt with in other co-ed treatment facilities.”
[“Linda” in, Aventa Outcomes and Community Impact Summary, 2017-2018 fiscal year, online.]

Aventa leaders’ advice for others who want to integrate TIC and GR-TIC into their organizations

When asked what advice they would offer to other organizations wishing to implement trauma informed care, Aventa leaders offered the following:

TIC is an organization-wide effort – an integrative approach; it must become embedded into everything that is done: “You can’t simply read a book and send staff off to training if you want to implement TIC”. Training is not enough.

Implementing TIC is like introducing any kind of change. This includes assessing what needs to be changed and why, and then looking at the resources that exist to help with the change.

It might be helpful to assess existing practices. For example, the BC Centre of Excellence for Women’s Health’s Trauma Informed Practice Guide (see its Appendix 2) includes an organizational assessment tool.

Start with training but don’t stop there.
- Find a training/approach that works for your organization and provide that to staff.
- Ensure there is a way to sustain this training as new staff come onboard.
- Evaluate and adapt or refine your training approach and bring in other aspects as needed.
- Support training with other organizational supports such as clinical supervision and supportive policies to reinforce and sustain good practices.

Look at your policies and make them more trauma informed; monitor this over time.

Dedicate resources (people, time, money) and supervision to ensure successful implementation of TIC.
- Capitalize on whatever information and resources are available and free. There are several good Canadian-based toolkits, some of which are listed at the end of this story. Capitalizing on these would be helpful, as would talking with other agencies about what they’re doing. This might be as simple as having staff complete some or all six of AHS trauma modules, and then building in training each month or quarter, then building in supervision.
- Consider developing a community of practice around TIC or create some other way of working on TIC collectively.
Endorse and resource ongoing monitoring, learning and adaptation – Aventa has an underlying philosophy of continuous quality improvement. People here are not afraid to try new things and if something doesn’t work, try to understand why, then try again. This culture helps ensure that learning is occurring, and adaptations are made as needed to continue to improve the care and services that are provided. [See the story, “Sustaining a culture of continuous learning at the Aventa Centre of Excellence for Women with Addictions”]

Photo by Fraser GermAnn, Community Mental Health Action Plan.

Intrigued? Encouraged? Want to make similar changes in your practice or organization? See Shared Wisdom for a smorgasbord of ideas for how you can make it happen.

Resources

The Aventa Centre of Excellence for Women with Addictions has an informative website that is well worth exploring.

Trauma-informed care

Alberta Health Services. Trauma informed care modules. https://www.albertahealthservices.ca/info/page15526.aspx

Alberta Health Services. Why Welcoming is Important handout: https://www.albertahealthservices.ca/assets/info/amh/if-amh-ecc-why-welcoming-is-important-qrs.pdf

Arthur, E., Seymour, A., Dartnall, M., Beltgens, P., Poole, N., Smylie, D., … Schmidt, R. (2013). Trauma-informed practice guide. Vancouver, B.C: BC Provincial Mental Health and Substance Use Planning Council.

Barnett Brown, V. 2018. Through a trauma lens. Transforming health and behavioral health systems. New York: Routledge.

Bloom, S. & Farragher, B. 2013 Restoring sanctuary. A new operating system for trauma-informed systems of care. New York: Oxford University Press.

Canadian Centre on Substance Abuse Trauma Informed Care

http://www.ccsa.ca/Resource%20Library/CCSA-Trauma-informed-Care-Toolkit-2014-en.pdf

Harris, M., & Fallot, R. D. (2001). Envisioning a trauma-informed service-system: A vital paradigm shift. New Directions in Mental Health Services, 89, 3-22.

Manitoba Trauma Information and Education Centre (MTIEC). 2013. Trauma-informed: The trauma toolkit (2nd ed.). Winnipeg, MB: Author.

Manitoba Trauma Information and Education Centre: http://trauma-informed.ca

Poole, N., & Greaves, L. (Eds.). 2012. Becoming trauma informed. Toronto, ON: CAMH.

SAMHSA. 2013. TIP 57 Trauma-informed care in behavioral health systems. Author.

Gender-responsive trauma informed care

BC Centre of Excellence for Women’s Health. Online. Trauma, Gender, Sex Informed Approaches to Substance Use videos: http://bccewh.bc.ca/featured-projects/traumagendersubstance-use-project-2/tgs-videos/

Canadian Women’s Foundation. Online. The facts about gender-based violence.

Covington, S. (2012). Curricula to support trauma-informed practice with women. In N. Poole & L. Greaves (Eds.) Moving the addiction and mental health system towards being more trauma-informed. Toronto: Centre for Addiction and Mental Health (CAMH).

Covington, S. (2008). Women and addiction: A trauma-informed approach. Journal of Psychoactive Drugs, SARC Supplement 5, 377-385.

Covington Curriculum: https://www.stephaniecovington.com/books-and-curricula.php

Schmidt, R., Poole, N., Greaves, L., & Hemsing, N. (2018). New Terrain. Tools to integrate trauma and gender informed responses to substance use practice and policy. Vancouver: BC Centre of Excellence for Women’s Health.

Endnotes

[i] Schmidt, R., Poole, N., Greaves, L., & Hemsing, N. (2018). New Terrain. Tools to integrate trauma and gender informed responses to substance use practice and policy. Vancouver: BC Centre of Excellence for Women’s Health.

[ii] Covington, S. (2012). Curricula to support trauma-informed practice with women. In N. Poole & L. Greaves (Eds.) Moving the addiction and mental health system towards being more trauma-informed. Toronto: Centre for Addiction and Mental Health (CAMH).

[iii] Aventa Centre of Excellence for Women with Addictions.(2018). Annual report 2017-2018. Author, pg. 11. Note also that Stephanie Covington also has a curriculum for men who have experienced trauma.

[iv] Covington, S. (2008). Women and addiction: A trauma-informed approach. Journal of Psychoactive Drugs, SARC Supplement 5, 377-385.

[v] It is also an exemplar of an organization that has embraced the power of ongoing learning and improvement to optimize services and outcomes. See the story, “Sustaining a culture of continuous learning at the Aventa Centre of Excellence for Women with Addictions” [insert link].

[vi] Covington, S., Burke, C., Keaton, S., & Norcott, C. (2008). Evaluation of a trauma-informed and gender-responsive intervention for women in drug treatment. Journal of Psychoactive Drugs, Suppl 5; 387-398.

Trauma Informed Care Aventa Story