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Violence can take many forms, and can occur once or many times during someone's life.

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Image description: Capital black letters read "SPEAK OUT." Background is white with parts of a larger drawing around it. Left bottom corner has a sideways heart with the word  "hurting" underneath in red marker. Navy blue line overlaps the word "out" and some sideways letters along bottom. Top middle of page has yellow lines.

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In addition to the short-term effects of violence, the long-term trauma can follow someone for several years following the event(s).

For many marginalized populations, discrimination and systemic violence are everyday experiences. People labelled/with intellectual disabilities are much more susceptible to abuse, and are less likely to report acts of violence (Spagnuolo & Earle, 2017).

People labelled/with intellectual disabilities are 2.9 times more likely to be physically assaulted, and 10.7 times more likely to be sexually assaulted than non-disabled people (Spagnuolo & Earle, 2017).

83% of women with disabilities will experience sexual abuse at some point in their lives. 40% to 70% of girls with intellectual disabilities will be sexually victimized before the age of 18 (Spagnuolo & Earle, 2017).

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Here are the helpful sources that have informed our research. We recommend reading the whole articles to gain a deeper understanding.

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Freeing our people: Updates from the long road to deinstitutionalization

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Freeing our people: Updates from the long road to deinstitutionalization

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This article is available in plain language here. Plain language is a style of writing preferred by many people with intellectual disabilities.
Dormitory at the Huronia Regional Centre, 1960. Mario Geo/Toronto Star
Imagine.

You are told when you will go to bed, when you will eat, and what you will eat.

You are denied a key to your own home, or to have visitors.

You are coerced or forced into sexual sterilization, for "your own protection."

You're informed the hours you spent shredding paper over 10 years are just a form of "training," and that you don't deserve even a minimum wage for this work.

You are told how to vote, or that someone else will vote in your place because you aren't capable of making rational decisions.

You're told you have "the mentality of a child."

You are told you should never have been born.

It's hard to imagine any adult being treated this way. But these are the insults faced every single day by people with intellectual disabilities. Under the guise of protecting them, many provinces practise intense forms of segregation that expose people with intellectual disabilities to degrading and abusive treatment.

Many are still locked away, against their will, in congregate care facilities and mega-institutions. They can be forced to toil in sheltered workshops for below minimum wage. Consequently, they end up living below the poverty line, completely reliant on punitive social assistance programs. They are set up for abuse, yet forbidden the tools, like adequate legal capacity, that would let them confront these practices and protect themselves.

While these are current and pressing issues, the situation reflects decades of systemic discrimination against people with intellectual disabilities. Today's government-established systems have roots in the century-old eugenic panic that worried "less intelligent" people were outbreeding "smarter" segments of the population. Our laws and policies reproduce these historic fears, if under a different lexicon: vulnerability is the current euphemism for "defective" and "unwanted."

The assumption of helplessness is a potent form of oppression that permits and justifies the removal of decision-making power. People First of Canada is part of a movement of self-advocates who, with their families and allies, are forcing governments to treat those with intellectual disabilities with respect. We have been fighting for deinstitutionalization for decades, based on the conviction, backed by extensive evidence, that social inclusion goes hand in hand with self-determination. "Nothing about us without us," as the saying goes.

Unfortunately, while it's been well-known for some time that people with intellectual disabilities in Canada are also at high risk of homelessness, abuse, sexual violence, criminalization, poverty and unemployment (see box), there has been little solidarity from progressive camps. No one appears to be listening. The information and evidence remains buried as a niche topic of little concern or interest to other policy researchers and social activists. This needs to change.

Violence

People with intellectual disabilities-especially women and girls-are at elevated risk for sexual violence.

Approximately 83% of women with disabilities will experience sexual abuse at some point in their lives. Girls with disabilities are four times more likely to experience sexual abuse.

Approximately 40% to 70% of girls with intellectual disabilities will be sexually victimized before the age of 18.

An estimated 20% of cases of sexual abuse against women with disabilities are ever reported to authorities.

People with intellectual disabilities are 2.9 times more likely to be physically assaulted, and 10.7 times more likely to be sexually assaulted than non-disabled people.
Discrimination
In Canada, 50% of discrimination cases relate to disability.

34.9% of people described as having cognitive disabilities (including intellectual disabilities) reported experiencing discrimination in the past 12 months, compared to 19.4% of people with other (not cognitive) disabilities and 10.6% of people without disabilities

28.9% of people with cognitive disabilities reported being a victim of some crime, compared to 20.4% of other (not cognitive) disabled people and 17.6% of people without disabilities.
Housing and homelessness
Among Canada's homeless population 45% identify as disabled; within this group, intellectual disability-a proven factor putting people at risk of homelesness-is disproportionately represented.

Almost 25,000 Canadians with intellectual disabilities (15.1%) experience core housing needs, compared to 11.1% of other people with disabilities (not intellectual) and 11.1% of people without disabilities.

In Ontario alone, an estimated 10,000 people with intellectual disabilities are on a waiting list for residential support (the wait time in Ontario was recently estimated at 22 years).

An estimated 100,000 to 120,000 adults with intellectual disabilities face housing and support gaps.
Poverty and employment
People with intellectual disabilities are among the poorest people living in Canada: 34.3% rely on social assistance, compared to 8.6% of people with other (not intellectual) disabilities.

20.6% of people with intellectual disabilities live below the low-income cut-off (LICO), compared to 12.5% of people with other disabilities and 10.3% of people without disabilities.

In 2011, the national employment rate for people with intellectual disabilities was 25.5%, compared to 47% for people with other disabilities and 74% for people without disabilities.

61.2% of people with intellectual disabilities are not in the labour force, compared to 41.9% of people with other disabilities.
Unmet health needs
People with intellectual disabilities experience some of the highest rates of psychiatric disabilities and have a high need for mental health services. Yet they tend to be overlooked and neglected in mental health policies, training and related efforts.
Sources: Canadian Civil Society Parallel Report for Canada, CRPD Committee (16th Session), February 27, 2017; "Meeting Canada's Obligations to Affordable Housing and Supports for People with Disabilities to Live Independently in the Community," submission to the Committee on the Rights of Persons with Disabilities for the 17th Session, March 2017; Unpublished data from the 2012 Canadian Survey on Disability compiled by Adele D. Furrie, Adele Furrie Consulting Inc; factsheet prepared for the Violence Prevention Initiative of the Government of Newfoundland and Labrador; Canadian Association for Community Living; Robert Blogh and Yona Lunsky, "The Invisibility of People with Developmental Disabilities," Policy Options, April 2017; Annual report of the Office of the Auditor General of Ontario, 2014.
Institutionalization today
Many readers will be shocked to learn that Canada still operates large institutions for people with intellectual disabilities. Images of these places are the stuff of horror films: imposing old buildings with white walls and barbed wire fencing, and where the doors lock upon closing. Inside staff restrain residents with straitjackets, subject them to chemical injections and confine them in time-out rooms.

But institutionalization isn't history, it's a thriving reality. The existence of these places poses an immediate threat to anyone labelled with an intellectual disability. About 900 people are languishing in large institutions (100 beds or more) in Manitoba, Saskatchewan and Alberta. And according to a civil society parallel report submitted to the United Nations this year by a group of Canadian disability organizations, these institutions continue to receive new admissions.

How do we explain this reluctance to deinstitutionalize? The most frequent excuse is that some people simply cannot cope-they are just "too disabled" to join society. People First of Canada and its allies in the deinstitutionalization movement believe, to the contrary, that with the right support all people can live within their community. The problem is that even though institutional care is billed as a "last resort" it quickly becomes the first or only option, given long waiting lists for alternate supports and false perceptions that a person's need are "too high." As a result, people with intellectual disabilities are being housed in traditional regional centres and group homes, nursing homes, senior homes, personal care homes and other long-term care facilities. They can even end up in homeless shelters or correctional facilities.

So-called trap doors to institutionalization exist via hospitalization and other warehousing practices that "store" people with intellectual disabilities in inappropriate settings. In many cases, hospitalization constitutes a costly form of institutionalization. In Ontario the costs of warehousing someone (without health needs) in hospital is $456,250 per year, or $1,250 a day. This amount greatly exceeds the average costs of supporting someone to live in the community, which, in the case of a group home for one adult, ranges from $21,400 to $310,000.

Advocates for deinstitutionalization have used this kind of fiscal reasoning to promote institutional closures. It clearly saves money-something those provincial governments who have agreed to decommission regional centres (the mega-institutions) almost certainly considered. Admittedly, it is troubling that closures have been achieved on these grounds, rather than on firmer principles of justice, the prevention of harm, or public exposure to what was taking place behind the scenes.

Survivors from Huronia (Ontario), Woodlands (B.C.), the Michener Centre (Alberta) and other institutions for people with intellectual disabilities have taught us that institutionalization breeds person-to-person violence. Successful class action lawsuits against provincial facilities have alleged high rates of sexual violence against people with intellectual disabilities; routine degrading treatment, such as group showers; the routine use of physical force, such as electric cattle prods; medical violence, such as forced or coerced sterilizations and teeth extractions (to facilitate "care"), and countless other atrocities.

Though Ontario Premier Kathleen Wynne apologized to survivors of such treatment in 2009, when the province shut down its three largest institutions (Huronia, Rideau Regional and Southwestern), the decision was largely a cost-saving measure. A decade earlier, Alberta issued an apology for the forced sterilizations carried out in many institutions under the notorious Sexual Sterilization Act. Yet the reproductive rights of women labelled with intellectual disabilities will be jeopardized as long as other institutions are being funded in this country.

The actions that follow institutional closures are as important as the closures themselves. Harsh survivors' stories continue to surface; these people must be given a platform and incorporated into policy decisions. Many self-advocates work toward preventing reinstitutionalization by memorializing the shameful legacy of these places and sharing histories of survivorship, as well as the stories of those who didn't make it out.

The grounds of the former Huronia institution include both unmarked and numbered graves, and survivors allege violent atrocities took place there. The space is nonetheless now considered prime real estate by the government, which is looking to sell. Infrastructure Ontario consulted the public earlier this year about the future of the 175-acre site and was expected to report on the results before the end of the spring.

One of the questions posed in Ontario's online survey was, "Do you think the Huronia Regional Campus is an appropriate site for cultural and/or recreational development?" It relates to a controversial proposal to transform the grounds bordering Lake Simcoe into something like Alberta's Banff Centre for Arts and Creativity. Project backers have encouraged the province to adopt a forward-looking vision, even suggesting that survivors and the public shouldn't "dwell on the lugubrious past" of the institution. Survivors and their allies believe it would be inappropriate to build a cultural centre on the Huronia site and that those who were hurt most by the institution should be included in the plans for its future-something they insist is not taking place.

Deinstitutionalization and the struggle to bring justice to survivors is as much about dignifying the memory of past wrongs as it is combating the isolation and poverty that continues to plague members of this community. Historical memory has a large part to play in preventing future atrocities and in restoring the full humanity of this group. Part of this work aims to encourage a culture change in how people with intellectual disabilities are perceived. In other words, society must work to recognize their histories, their right to decision-making, and their entitlement to a dignified standard of support.
Group homes and other trap doors to institutionalization
There are many new and lingering forms of institutionalization, as well as trap doors that lead back to reinstitutionalization. More than ever, we need to ensure that whatever follows in the wake of institutional closures does not repeat past mistakes. Keeping control of services in the hands of people with intellectual disabilities, their families and allies, and not in the hands of the market-oriented "disability business," is extremely important in this respect.

Oncemajor institutions are closed, many of their former residents end up living in group homes that offer supported living arrangements. Data on exactly how many people are affected in this way is hard to come by. Group homes operate in a decentralized environment; non-profit agencies are responsible for managing both the real estate and the staffing of the home. Disturbingly, the living conditions in group homes reflect the same problems that existed-and still exist-in larger institutions. So strong are the similarities that these homes, some of them managed by the same people who previously operated institutions, have been dubbed "mini-institutions."

Approximately 30,000 adults with intellectual disabilities live in congregate care facilities and group homes.

Approximately 10,000 adults under 65 with intellectual disabilities are forced to live in hospitals, nursing homes and similarly unsuitable long-term care environments due to a shortage of housing and support options.
Source: "Meeting Canada's Obligations to Affordable Housing and Supports for People with Disabilities to Live Independently in the Community," submission to the Committee on the Rights of Persons with Disabilities for the 17th Session, March 2017.

People First of Canada defines an institution as "any place in which people who have been labelled as having an intellectual disability are isolated, segregated and/or congregated. An institution is any place in which people do not have, or are not allowed to exercise, control over their lives and their day to day decisions. An institution is not defined merely by its size." Deinstitutionalization therefore means closing all institutions-including group homes-that inappropriately house people with intellectual disabilities. Whether an institution houses 600 people in a single building or six in a suburban bungalow is irrelevant.

Group home providers frequently claim they help support community inclusion. But more often than not, these mini-institutions are present in the community only in a physical sense. The nature of support, the routinization of daily life and the overall lack of freedom, choice and dignity remain the same as what one would experience in a large institution.

Residents don't have the freedom to choose their own roommates or even the location of their home. Even fewer have opportunities to learn about self-advocacy, to reflect on their life experiences, and to share their stories with peers and the community at large. The primary concern is filling beds and working around the needs of staff. Routines are established and residents must adapt to the prescribed rhythm, regardless of whether it suits their needs or preferences.

Consistent with the lack of available data on how many people are living in group homes, it is very difficult to ascertain how much money is spent to sustain them in any given province or territory. Partly this is because of how many different departments or agencies tend to be involved in funding decisions. Although the salaries of agency managers or directors will vary, support workers can earn lower wages than frontline food service employees. These low salaries, which often result in high turnover rates at group homes, reflect the low value that is put on the care and support of people with intellectual disabilities.

In contrast to the paucity of information about group home finances, local and national news reports are littered with stories of neglect, abuse, assault and even murder in nursing and group homes across Canada. In 2009, a stunning 53 lives were lost in Ontario group homes for people with intellectual disabilities. Some such deaths are the result of interventions by police, who are occasionally called to group homes by staff who feel threatened by residents. For example, Aron Firman died in a group home in Collingwood, Ontario after being tasered by police in 2010. In 2009, Douglas Minty, a man with an intellectual disability living in Elmvale, Ontario was shot and killed by police outside his home.

Add racial profiling by police to the mix and interactions with disabled members of the Indigenous and Black communities become even more fraught. Last summer, Abdirahman Abdi, a 37-year-old disabled Ottawa man who was Black, Somali and Muslim, died from injuries he suffered at the hands of the police (the officer was charged with manslaughter in March). Later that year in Brampton, police were called to the group home of Marlon Bailey-Lee, a 21-year-old Ontario man who is Black and who does not use verbal communication. The visit was prompted by a dispute he had with his support staff and resulted in his being repeatedly tasered.

People with intellectual disabilities are also at risk from accusations by the people assigned to look after them. Nova Scotian Amanda Murphy was arrested in 2014 after an encounter with support staff. In a similar incident in a large congregate care facility in Nova Scotia, Nichelle Benn was charged with assault after allegedly biting a staff person and throwing a shoe and foam letter. Charges against Benn were only dropped after a seven-year battle that included protests by People First members. These cases expose an uneven power struggle between residents with intellectual disabilities and a system designed to contain them.
When will we do better?
In place of containment in institutions and group homes, People First of Canada argues that people with intellectual disabilities have the right to exercise choice in determining their own living arrangements. A popular and very plausible alternative to the group home and congregate care system is direct funding.

When money is tied to the individual, rather than to an agency or geographical region, it provides greater choice and control, and the flexibility to tailor additional support to those who require assistance in managing their finances and in making decisions. Direct funding is more humanizing, since where a person lives is a matter of choice and not dependent on the availability of beds within agencies.

Unfortunately, the logic behind personalized support has been co-opted by a chaotic "disability industry"-a confusing mishmash of not-for-profit private businesses, case-management services, person-directed planning services and others vying for public dollars. Furthermore, missteps in managing the consequences of institutional closures are leading to new forms of institutionalization. Many people are experiencing, or are at risk of experiencing, reinstitutionalization, including those who managed to survive provincially run institutions.

Once we begin to recognize the institutional patterns that are cropping up in new support models, like group homes, we can get to work on replacing them. To avoid past mistakes-and avoid paternalism-it is essential that input from self-advocates and other people with intellectual disabilities form the basis of policy solutions. People with intellectual disabilities are reclaiming their right to speak for themselves and to redefine their lived experience on their own terms.

But the fight for deinstitutionalization and desegregation remains an underground struggle waged by a group of people whose very humanity continues to be questioned. People with intellectual disabilities are simply not on the radar of most progressive think-tanks-even though their experiences overlap with major social issues, and despite their presence near the top of many data sets on poverty, sexual violence, homelessness, unemployment, and criminalization. They have no substantive rights in Canada. Among disabled people, they are truly the left behind of the left behind.

As recently as the early 1990s, a period when other disabled people were making gains in the U.S. and Canada, public intellectuals like the Australian philosopher Peter Singer were comparing those with intellectual disabilities to animals to justify murdering them. Earlier this year, Singer weighed in on a disability rape case in a coauthored New York Times op-ed claiming the alleged victim was both incapable of consenting and not sufficiently "intelligent" to understand that he had even been raped in the first place. Clearly, Singer has learned nothing in over 30 years of debating and engaging with disability advocates.

But how can we expect any better of people when the use of the "R" word is still rarely challenged outside of disability communities? How can we expect any better from society when our own government continues to fund deeply segregated, dehumanizing and dangerous forms of support for people with intellectual disabilities? Out of sight, out of mind has hidden many disturbing facts about intellectual disability from the public for far too long.

We can no longer say that we didn't know any better. We can no longer say we can't do any better. These wrongs must be righted and further abuse prevented. We need to bring the "left behind" forward if we are to become an inclusive and accessible country.

Sheltered workshops offer sub-minimum wages

Sheltered workshops are places where people with disabilities are "employed" for below minimum wage. Employers justify unacceptably low (and in any other situation illegal) "training wages" by claiming they are providing opportunities for social participation and life skills development. Other rights and concerns are readily swept aside to promote "inclusion" under this faulty framework.

According to the 2017 civil society parallel report (see above), "Although enrollments in sheltered workshops are slowly declining, sheltered workshops, segregated day programming and enclave-based employment persist as a dominant model of support for persons with disabilities, particularly those with intellectual disabilities." The persistence of this model is partly explained by employers framing activities as "training programs," according to a 2011 report by the Canadian Association for Community Living.It is hard to ascertain the number of people with disabilities who are toiling in these workshops.

A Toronto Star series on the issue, published in November 2015, said "the Ministry of Community and Social Services, which funds developmental services, does not know how many sheltered workshops exist or how many people work in them." Fewer than half the agencies that provide segregated employment settings responded to a government survey, explained one article. Based on the limited responses to that survey, we know that at least 3,463 individuals are working in 52 workshops in Canada.

Since the Toronto Star series came out, the ministry has said it will close Ontario's workshops forever, which has already helped decrease the number of people with disabilities in sheltered workshops in Ontario. But again, we don't have any hard numbers to back that up.

People First of Canada believes in "real work for real pay." People with intellectual disabilities should have opportunities to earn a living through paid employment of their own choice in the labour market. Employers must be open to a diverse workforce. Job accommodations and supports need to be provided. Wages and benefits should be equal to those of persons without disabilities.

Natalie Spagnuolo is a PhD candidate in critical disability studies at York University and sits on the social policy committee of the Council of Canadians with Disabilities. Kory Earle is President of People First of Canada/Personnes d'abord du Canada and a member of the Council of Canadians with Disabilities' executive committee.
This article was published in the July/August 2017 issue of The Monitor. Click here for more or to download the whole issue.

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Freeing our people: Updates from the long road to deinstitutionalization

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This article is available in plain language here. Plain language is a style of writing preferred by many people with intellectual disabilities. Dormitory at the Huronia Regional Centre, 1960. Mario Geo/Toronto Star Imagine. You are told when you will go to bed, when you will eat, and what you will eat.

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On this page:
Testimony of mother volunteers
Rubber punishment
Benching
Psychological Suffering:
"Side" Room or "Punishment" Room
Cage-Cots
Wet-Packs, Cold Baths, Straight Jackets (Restraints) and Sheet Restraints

At the Orillia institution there seemed to be no cohesive standard of discipline, and punishment was meted out at will by attendants, (later called 'workers'), warders, nurses and nursing assistants, generally referred to as 'Staff'. Beatings were endemic, also patients being punched, cuffed, kicked, having their heads bashed against a wall, or shoved down a toilet bowl.

Survivor Michael Callahan recalls children beaten with a wooden club if their hands were dirty at inspection. Marie Slark had her head dunked in a bucket of cold water for not eating. Danger and injury often came from other patients, either not noticed due to the overcrowding and understaffing, or ignored. Michael C. was once stabbed in the back by another patient wielding a home-made knife.

Government inspector Dr Snedden, examining the hospital in 1956, found three padlocks under a patient's mattress and metal knives.

In 1960, Pierre Berton, news reporter for the Toronto Daily Star, reported a patient who suffocated to death after another patient let off a piston of steam after a fire.

The Willard Report of 1976, commissioned by the government of Ontario, which examined conditions in the Huronia institution, cited a murder committed by a former patient, and a horrific rape and murder of a patient in the 1970s.

Charges were rarely made against staff. Children were threatened by staff that they would face worse punishment if they reported abuses or complained to other staff, administration, or parents, though in the 1970s, two male staff were charged with physical abuse of patients.

Group punishments were often accompanied by humiliation, such as the infamous "rubber punishment" that most patients interviewed recalled.

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Punishment and Cruel Treatment - Thelma Wheatley

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On this page: Testimony of mother volunteersRubber punishmentBenchingPsychological Suffering:"Side" Room or "Punishment" RoomCage-Cots Wet-Packs, Cold Baths, Straight Jackets (Restraints) and Sheet Restraints At the Orillia institution there seemed to be no cohesive standard of discipline, and punishment was meted out at will by attendants, (later called 'workers'), warders, nurses and nursing assistants, generally referred to as 'Staff'.

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Image description: Black capital letters that read "EVERYONE INCLUDING PEOPLE WITH DISABILITIES DESERVES PRIVACY." 6 black stars comprised of sticks running down both sides of words. Black line on bottom.

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Huronia: Pierre Berton warned us 50 years ago 

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Huronia: Pierre Berton warned us 50 years ago 

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On Tuesday, the Ontario government settled a class-action suit with former residents of Huronia Regional Centre in Orillia. The terms include $35 million and a formal apology. The problems at the government-run institution for the developmentally delayed go back decades, and so do warnings. (The centre was known as the Ontario Hospital School, and earlier as the Orillia Asylum for Idiots.) Author Pierre Berton wrote a haunting report for the Toronto Daily Star on Jan. 6, 1960, reprinted here.
On the last afternoon of 1959, I drove to Orillia with a friend of mine and his 12-year-old son. The boy is handsome, with large, dark eyes, but he is not very communicative for he will always have the mind of a child. He is retarded mentally. On holidays he comes home to his parents. The rest of the time he is a patient at the Ontario Hospital school.

There are 2,807 others like him, jammed together in facilities which would be heavily taxed if 1,000 patients were removed. More than 900 of them are hived in 70-year-old buildings. There is nowhere else for them to go.

It is distressing to visit these older buildings, as I did last week. The thought of fire makes the hair rise on your neck. The stairways have been fireproofed; nothing else. The paint peels in great curling patches from the wooden ceilings and doors. Gaping holes in the worn plaster walls show the lath behind. The roofs leak. The floors are pitted with holes and patched with ply. The planks have spread and split, leaving gaps and crevices that cannot be filled.

The beds are crammed together, head to head, sometimes less than a foot apart. I counted 90 in a room designed for 70. There are beds on the veranda. There are beds in classrooms. There are beds in the occupational therapy rooms and in the playrooms that can no longer be used for play. On some floors the patients have nowhere to go except out into the corridors.

The stench here is appalling, even in winter. Many patients are so helpless they cannot be toilet trained. The floors are scrubbed as often as three times a day by an overworked staff but, since they are wooden and absorbent, no amount of cleansing will remove the odors of 70 years.

On one floor there is one wash basin to serve 64 persons. On another floor, where the patients sometimes must be bathed twice or three times a day, there is one bathtub for 144 persons - together with three shower outlets and eight toilets. Prisoners in reformatories have better facilities.

Designed for the wrong patients

The newer "cottages," as they are euphemistically called, are often excellently designed, clean and fireproof - but they, too, are overtaxed and often misused. Buildings built in 1932 for 144 patients now house 220. And because they have been fireproofed, they now have the wrong patients in them. They were designed to serve high-grade patients - those with an I.Q. of 50 or more. But, because of the threat of fire, the more helpless inmates have had to be placed in them. Those of higher intelligence have been switched to the non-fireproof buildings because they are better able to escape on their own.

The authorities face a serious dilemma at Orillia. In order to fireproof the old buildings they would have to evacuate all the patients. But there is nowhere to move them. They could, of course, erect new buildings, then tear the old ones down. But the waiting list for the hospital school is so large nobody really believes they could be torn down - even if others were built. There are just too many people knocking on the door.

There are 4,000 names on the file at Orillia - names of people who have applied to enter a retarded child in the institution. The active waiting list - of people who have written within the last year - is 1,500. Even the new hospital school being completed at Cedar Springs cannot accommodate this number.

In 1949, Orillia admitted 196 new patients. In 1959, the number had grown to 310. At the present time they are coming in at the rate of three a day. The hospital loses, by death or discharge, less than half the number it admits annually. And so the terrifying problem builds up year by year.

There are several reasons for this. One, obviously, is the population increase: for every 200 children born this year in Ontario, three will need institutional care. Ironically, too, medical advances have almost doubled the lives of many mentally retarded patients. The big move to the cities has made it difficult to care for a retarded child at home, and the "village idiot" of our forefather's day is likely to be a patient at Orillia now. Finally, because of a change in public attitudes, people seek out institutions which they once shunned.

A patient suffocates to death

Orillia is overcrowded and understaffed. These two evils recently produced a chain reaction that caused a patient's death. Three years ago there was a bad fire in the basement of one of the older buildings. The danger was so great that a supervising nurse from the neighboring infirmary was called to help evacuate the inmates. All were saved but, in the nurse's absence, an infirmary patient released a cloud of steam which caused one woman to suffocate.

Political considerations have made Orillia's situation more acute. The hospital was originally designed for children of six years and older. It is now heavily overcrowded with children under that age. Medical authorities are convinced that many of these would be better off at home during the early years. But many have by-passed the waiting list and the regulations because of pressure from Ontario MPP's.

Construction and renovation at Orillia comes under the Department of Public Works, long the focus for political patronage in Ontario. Until recently, the department has had little liaison with the Department of Health which operates the hospital schools. Instead of rebuilding from the ground up, to careful plans, it prefers to work in a piecemeal manner - patching and renovating. Often the pace seems maddeningly slow. The remodelling of the administration building at the hospital began last April. It's still not complete. By contrast, a private contractor completed the floor-to-ceiling remodelling of the Orillia YMCA, a $250,000 job, in just four months.

But Orillia's real problem is one of public neglect. It is easier to appropriate funds for spectacular public projects such as highways and airports than for living space for tiny tots with clouded minds. Do not blame the present Department of Health for Orillia's condition. Blame yourself.

Remember this: After Hitler fell, and the horrors of the slave camps were exposed, many Germans excused themselves because they said they did not know what went on behind those walls; no one had told them. Well, you have been told about Orillia. It is, of course, no Belsen. In many respects it is an up-to-date institution with a dedicated staff fighting an uphill battle against despairing conditions. But should fire break out in one of those ancient buildings and dozens of small bodies be found next morning in the ashes, do not say that you did not know what it was like behind those plaster walls, or underneath those peeling wooden ceilings.

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Huronia: Pierre Berton warned us 50 years ago

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On Tuesday, the Ontario government settled a class-action suit with former residents of Huronia Regional Centre in Orillia. The terms include $35 million and a formal apology. The problems at the government-run institution for the developmentally delayed go back decades, and so do warnings.

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Trauma occurs when people experience an overwhelmingly negative event or series of events, including violence (Government of Canada, 2018).

Research indicates that youth labelled/with intellectual disability experience exposure to trauma at a higher rate than their nondisabled peers (Government of Canada, 2018).

This part of the population also appears to be at an increased risk for physical abuse, physical restraint and seclusion, sexual abuse, and emotional neglect (Government of Canada, 2018)

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Table of Contents

Introduction

Trauma-informed approaches are familiar to many organizations and service providers. Recently, this term has been expanded to include "and violence", an important change in the language which underscores the connections between trauma and violence.

Trauma and violence-informed approaches are policies and practices that recognize the connections between violence, trauma, negative health outcomes and behaviours. These approaches increase safety, control and resilience for people who are seeking services in relation to experiences of violence and/or have a history of experiencing violence.

Trauma and violence-informed approaches require fundamental changes in how systems are designed, organizations function and practitioners engage with people based on the following key policy and practice principles:

1. Understand trauma and violence, and their impacts on peoples' lives and behaviours

2. Create emotionally and physically safe environments

3. Foster opportunities for choice, collaboration, and connection

4. Provide a strengths-based and capacity-building approach to support client coping and resilience

Service providers and organizations who do not understand the complex and lasting impacts of violence and trauma may unintentionally re-traumatize. The goal of trauma and violence-informed approaches is to minimize harm to the people you serve-whether or not you know their experiences of violence.

Embedding trauma and violence-informed approaches into all aspects of policy and practice can create universal trauma precautions, which provide positive supports for all people. They also provide a common platform that helps to integrate services within and across systems and offer a basis for consistent ways of responding to people with such experiences.

Why we need trauma and violence-informed approaches

Violence is pervasive in society (for example, globally 1 in 3 of women experienced physical and/or sexual violence by a partner or sexual violence by a non-partner; in Canada 32% adults report that they experienced abuse in childhood; and 25% of students in grades 6-12 report being bullied). Because of this, many people seeking services-in health care, housing, justice or other systems-will have histories of violence and trauma.

The goal is to minimize harm, not to treat trauma

Trauma and violence-informed approaches are not about 'treating' trauma, for example, through counselling or chronic pain interventions. Instead, the focus is to minimize the potential for harm and re-traumatization, and to enhance safety, control and resilience for all clients involved with systems or programs. These approaches benefit everyone, whether or not they've experienced trauma in their lives or their personal history is known to service providers.
The connections between trauma and violence

Trauma is both the experience of, and response to, an overwhelmingly negative event or series of events, including violence

Violence can take many forms, and can occur once or many times during someone's life

Violence can have traumatic long-term effects, whether the violence is ongoing or in the past.

Three important reasons to implement trauma and violence-informed approaches

1. To increase attention on the impact of violence on people's lives and well-being

Concepts of trauma-informed practice or care have been emerging over the past 15 years. The addition of "and violence" is a recent and important change in language that helps to:

Understand violence and its relationship to trauma

Recognize that, like past violence, ongoing violence may be a primary cause of trauma responses

Reduce the tendency to blame/judge people for their psychological or behavioural reactions to experiences of violence, and recognize that these responses may be a result of trauma

Distinguish how trauma that results from violence is different from trauma caused by other negative events, such as natural disasters

Connect to broader systems

Draw attention to the cumulative effects of multiple forms of violence including systemic violence, such as racism or discrimination

Direct attention to the importance of organizational-level actions, such as changes to policies that take clients' safety and experiences of violence into account and that recognize how broader conditions of people's lives (e.g. poverty or unstable housing) increase risk of multiple forms of violence. These could include staff/client ratios, waiting area policies and social policies.

2. To reduce harm

Service providers, organizations and systems may not be aware that they can cause unintentional harm to people who have experienced violence and trauma.

People who interact with systems such as justice, health, housing and child protection can be re-traumatized by their experiences in these systems. Re-traumatization can happen each time an adult or child needs to re-tell their story of abuse when seeking help across sectors, organizations or service providers, or when people experience discrimination, marginalization or stigma.

Service providers can inadvertently re-traumatize or trigger their clients when they:

touch without warning or permission

speak in a way that conveys negative judgement or blame, such as, "Oh, you're back again", or, "Why don't you just leave your partner?"

interpret a client's reaction or behaviour as being out of proportion or unwarranted without considering the experiences which may have contributed to the reaction or behaviour

use forceful or demanding language to tell a client to complete a task-such as fill out a medical history form or remove clothing for an examination

3. To improve system responses for everyone

Trauma and violence-informed approaches can help make systems and organizations more responsive to the needs of all people and provide opportunities for practitioners to provide the most effective support to their clients.

These approaches aim to increase the safety, control and resilience of all clients, regardless of whether or not they have experienced violence or trauma sometime in their lives.
Universal trauma precautions provide safe care for all
Embedding trauma and violence-informed approaches into all aspects of policy and practice create universal trauma precautions that reduce harm and provide positive supports for all people.

Disclosure of violence and trauma is not the goal in trauma and violence-informed approaches. Service providers do not necessarily need to know peoples' violence histories to provide appropriate support.

By practicing universal trauma precautions, service providers can offer safe care or support, even when individuals choose not to disclose their trauma history. Here are some of the many reasons why individuals may choose not to disclose:

it is unsafe to disclose

the history is not central to the immediate service being provided

a client has limited or no memory of their history

the client finds it too distressing to disclose

How trauma and violence are connected

Trauma occurs when people experience an overwhelmingly negative event or series of events, including violence.

Violence can take many different forms and can be experienced once or many times. Violence is often the result of intentional actions to control or abuse someone, but can also have unintended consequences, such as when children are exposed to intimate partner violence. Experiences of violence can also be systemic and less visible. For many marginalized populations, discrimination and systemic violence are everyday experiences.

Different forms of violence can have interrelated traumatic effects

Examples:

Child maltreatment can increase a person's vulnerability to interpersonal violence in adulthood

Children's exposure to intimate partner violence can result in negative health and social outcomes similar to those resulting from more direct forms of abuse

Exposure to systemic violence (such as racism) can increase a person's vulnerability to all other forms of violence

Over time, experiences of systemic violence can result in historical and intergenerational trauma

Self-directed violence often arises in the context of exposure to interpersonal forms of violence

Trauma can cause neurobiological changes which impact health and behaviour across the lifespan

For example, child abuse, including neglect and exposure to intimate partner violence, can impact children's emotional and social development- including lifelong patterns of anxiety, chronic pain, substance use or difficulty controlling anger.
Triggers can reactivate trauma
Neurobiological changes caused by trauma can result in triggers, whereby present day events can recreate past traumatic experiences so that potential threats are perceived as real- whether they are real or not.

Commands, touches, sounds, smells or other physical sensations can remind people of early trauma and trigger a response

For example, touching a person without warning or permission can trigger an automatic flight or fight response

How gender and culture are connected to trauma and violence

Trauma and violence-informed approaches recognize that experiences and effects of violence are strongly linked to gender and culture.

Gender

Trauma and violence-informed policies and practices recognize that violence and trauma are shaped by gender stereotypes and inequities, and thus tailor services and programming to individual needs. Adults, children and youth of all gender identities face different levels and types of risks, as well as varying access to service and support.

Overall, rates of intimate partner violence are higher for women compared to men in every age group. Certain groups of women experience higher rates of violence than other women, particularly Indigenous women and women with disabilities. Violence against women is rooted in gender inequity and women are more likely to:

report ongoing violence, physical injury, more serious types of injuries and greater health issues

experience coercive control

have greater fear of physical injury and death

experience sexual violence

Girls have a higher risk than boys of being sexually abused

Boys have a higher risk than girls of being physically abused

Men are socialized away from disclosing family violence and seeking help
While women and men experience emotional/psychological intimate partner violence at similar rates, men experience it along with fear of ridicule, humiliation and degradation

Transgender people, which includes people who may also identify as lesbian, gay, bisexual, and two-spirited, experience much higher rates of domestic and community violence than the general population and face extensive barriers to service

Culture

Culture is also important in the Canadian context where Indigenous people experience multiple forms of disadvantage, interrelated with disproportionately high rates of violence. Newcomers, some people of colour and people from other groups that are marginalized in Canada, face assumptions about how their culture contributes to experiences of violence. Such assumptions can create barriers to effective service and support. For example, service providers may assume that women from racialized ethnic communities who experience intimate partner violence will have high levels of support from their communities, whereas in reality, the women may be ostracized.

Cultural safetyEndnote xiii is an approach to working across ethnic and other differences to make systems and organizations responsible to ensure that service environments are safe for everyone-regardless of their expressed or assumed culture. This approach to policy and practice is compatible with, and often an embedded component of, trauma and violence-informed approaches.

For example, service providers support cultural safety when they

How to implement trauma and violence-informed approaches

Trauma and violence-informed approaches require fundamental changes in how practitioners engage with people, how organizations function and how systems (such as the health system and the justice system) are designed. These approaches can result in more beneficial ways to view and treat people, which can lead to more successful outcomes for clients.

For individual practitioners, a change in strategy means attempting to eliminate assumptions about people who experience violence and trauma and their actions. For organizations and systems, it means supporting a culture of learning and capacity-building to create safe environments for clients and staff.

Four principles for implementing trauma and violence-informed approaches

1. Understand trauma and violence and their impacts on peoples' lives and behaviours

Service providers

Acknowledge the root causes of trauma without probing. Your clients do not necessarily need to disclose what may have happened to them for you to help them
"I know that people who have had difficult experiences often have difficulty trusting people in authority, or have chronic pain."

Pause and reflect when someone acts or reacts in an unexpected way
"What happened to this person?" vs. "What's wrong with this person?"

Listen, believe and validate victims' experiences
"That sounds like a horrible experience." or "No one deserves to be treated like that."

Recognize their strengths
"You have really survived a lot."

Express concern
"I am really concerned for your safety."

Organizations and systems

Develop organizational structures, policies and processes that foster a culture built on an understanding of how trauma and violence affect peoples' lives

Develop hiring practices that seek people who understand trauma and violence and reward systems that compensate employees for building their competencies in this area

Train all staff on the connections between violence, trauma and health outcomes and behaviours, including vicarious or secondary trauma

See this principle in action.

2. Create emotionally and physically safe environments

Service providers

Communicate in non-judgemental ways so that people feel deserving, understood, recognized and accepted
"I am happy to see you came in today."

Foster an authentic sense of connection to build trust
"I can see from your body language/face/comments that you don't agree with what I've said. What are you thinking about right now? What are you worried about?"

Provide clear information and consistent expectations about services and programs
"I can't give/provide you with [that service] because of the rules I have to follow. But I'd like to help you find other ways to help manage your situation."

Encourage clients to bring a supportive person with them to meetings or appointments
"If bringing a family member or friend or someone else would help you feel more comfortable at our next meeting, you are more than welcome to do so."

Organizations and systems

Walk through your practice setting to see and assess how a client might experience each moment. This simulation can help identify where improvements can be made. For example:

Travel to the site on bus and see what it feels like to arrive at the service site. Is it difficult to access?

Spend time in the waiting area, fill out the forms and experience how long a client might wait to be seen.

Go through all client activities, such as being asked to undress/put on a gown, being physically examined or asked sensitive questions.

Pay attention to welcoming intake procedures and signage, comfortable physical space, consideration of confidentiality

Seek client input for inclusive and safe strategies

Create policies and structures to allow clients to bring a support person with them to meetings

Provide support for service providers at risk of secondary trauma and facilitate their self-care.

Consider peer support, regular clinical supervision and self-care programs.

See this principle in action.

3. Foster opportunities for choice, collaboration, and connection

Service providers

Provide choices for treatment and services, and consider the choices together
"Last time you were here, we had a plan to try [strategy x]. How did that work out for you? What about our plan would you like to change?"

Communicate openly and without judgement
"In order to provide the best care possible, it's helpful for me to know about people's alcohol use. Could you tell me how much you drink? IF YES, "okay, and can you tell me how often you drink? for example, most days? once a week? once a month?" NOTE: Start with most days.

Provide the space for clients to express their feelings freely
"Is there anything you would like to tell me that might be helpful for our work together?"

Listen carefully to the client's words and check in to make sure that you have understood correctly
"So it sounds like your living situations is ... difficult, stressful, etc."

Organizations and systems

Offer training and professional development opportunities for staff on:

the importance of critical self-reflection on power differences between practitioners and clients

how experiences of violence can influence the way that clients engage with providers

Set expectations, create opportunities and provide the time and space for collaborative relationships to be formed between (e.g. generous appointment time allocations, clients' advisory mechanism)

See this principle in action.

4. Provide a strengths-based and capacity-building approach to support client coping and resilience

Service providers

Help clients identify their strengths, through techniques such as motivational interviewing, a communication technique that improves engagement and empowerment

Acknowledge the effects of historical and structural conditions on peoples' lives
"Life circumstances often make it difficult to move forward in your life, like finding housing or getting a job."

Help people understand that their responses are normal
"It's understandable that you feel angry about being treated unfairly. It sounds like you feel you were dismissed."

Teach and model skills for recognizing triggers, such as calming, centering and staying present

Organizations and systems

See this principle in action.

Addressing the impact on service providers who work with people who have experienced violence and trauma

Service providers who work directly with people who have experienced violence often hear difficult stories and witness the impact of these experiences.

depression, emotional exhaustion and anxiety

sleep disturbances and intrusive thoughts

trigger responses to external events, some of which may seem harmless to others

Organizations can help reduce secondary trauma for service providers

The negative impacts of secondary trauma are associated with employee burnout and high turnover, both common in sectors where service providers work directly with people who experience violence.

Organizations can help reduce secondary trauma for their employees with trauma and violence-informed policies and practices that:

actively support the well-being and self-care of service providers who are repeatedly exposed to others' stories of violence

help providers to understand peoples' responses to violence, including their own

help to prevent 'trigger responses' for both clients and providers

When they are well-supported by trauma and violence-informed approaches and workplace wellness programs, service providers can find satisfaction and growth in their work, despite the challenges.

Examples of trauma and violence-informed approaches
Principles in action
The following examples of trauma and violence-informed programs and policies have been implemented in a wide range of sectors in Canada. They are organized according to the four guiding principles for implementing trauma and violence-informed approaches.

Principle 1- Understand trauma and violence and their impacts on peoples' lives and behaviours

Housing
Supportive policies for women mean better access to safe and affordable housing
Atira Women's Resource Society provides housing across the lower mainland of BC to women who have experienced violence. The Society serves women with a range of health and other support needs, and women who experience multiple forms of marginalization and systemic violence.

A core premise of Atira's policy and practice is recognition that violence and trauma contribute to many of the challenges women face to secure safe and affordable housing.

Here are some ways that Atira has changed its policies:

It does not require women to disclose experiences of abuse in order to access housing

It creates opportunities for extended and specialized forms of housing for women, rather than an earlier policy which had a 30-day limit for women in shelters

It hires women with lived experience of violence and homelessness

It is inclusive of women who use substances

Community Health Centre
Reducing stress for clients and staff through a change in clinic practices
Cool Aid Community Health centre, which serves clients who live on low-incomes, used a trauma and violence-informed approach to review their practices.

They recognized that when clients had to line up on the street to wait for the clinic to open, they were exposed to forms of violence, including demeaning behaviour by people passing by. For example, vulnerable clients were intimidated by drug dealers, asking to 'share' their prescriptions. Clients often had inadequate clothing to protect them from the elements, particularly in winter. Additionally, clinic receptionists were negatively impacted when witnessing these situations and felt responsible for the clients' well-being.
This program is trauma and violence-informed because...

It identified an environment that was emotionally and physically unsafe for their clients-particularly the most traumatized- and changed it

It reduced the vicarious trauma experienced by clinic receptionists who witnessed clients being victimized every day, and felt responsible for the line-up

Principle 2-Create emotionally and physically safe environments for both clients and service providers

Integrated Service Provision
Children's Advocacy Centres provide child-centred approaches for victims of abuse
Children's Advocacy Centres (CACs) are child-friendly centres that coordinate the investigation, intervention and treatment of child abuse, while helping abused children and their non-offending family members navigate service systems and recover from experiences of violence. CACs provide a comprehensive response by a multidisciplinary team of service providers who work in areas including:

By conducting joint interviews during the investigative phase of the work, this multidisciplinary team is able to minimize the number of times a child needs to re-tell their story of abuse. Overall, the CAC approach creates a more efficient and effective investigation of child abuse cases than traditional approaches. CACs also offer a range of treatment and support services for children, youth and their families, with fewer services overlapping or conflicting. Child-friendly space is included in the design of CAC offices to help children feel comfortable and safe.

Child and Youth Advocacy Centres is the national network of CACs, and include the Regina Children's Justice Centre, BOOST Child and Youth Advocacy Centre, Zebra Child Protection Centre and the Sheldon Kennedy Child Advocacy Centre.

Sexual Assault Centre

Self-care for service providers as an integral component of ethical care and case management

Fredericton Sexual Assault Centre (FSAC) provides trauma support and counselling to people affected by sexual and dating violence. The Centre is grounded in the concept of trauma stewardship, a trauma and violence-informed approach that ensures that service providers care for themselves while they are providing ethical care and management of other people's trauma.

Being a steward of other people's trauma can have real consequences for the service provider, including vicarious or secondary trauma, compassion fatigue and burnout. It can also lead to serious physical and mental health issues and can compromise the ability of staff and volunteers to provide optimal care and support. The focus of trauma stewardship is to recognize the impacts of working with survivors of trauma. It identifies strategies for individual service providers and for the organization to mitigate these adverse consequences and promote staff well-being.

FSAC uses three strategies under their trauma stewardship program:

1. Debriefing that limits staff and volunteer exposure to stories of trauma. This low-impact approach encourages people to:

ask permission from colleagues before sharing information, to warn them that they may be hearing something difficult

talk about a situation as part of their self-care

start from the "outside edges of the story", and work their way in, focusing on their feelings about the interaction with a client rather than on the intense details of the incident

2. Weekly, trauma-informed Yin yoga sessions for staff, during staff hours and at no cost

3. A mandatory crisis line report form requires volunteers to indicate how they are feeling after a call and what self-care practices they plan to use. If a more active debrief is necessary, they are encouraged to contact a peer support system

Principle 3-Foster opportunities for choice, collaboration and connection

Corrections Services
Giving back promotes meaningful engagement for men in prison
Work to Give is a program that supports men in prison to produce needed items for First Nations families and children who live in poverty in central BC. The men produce food, furniture, clothing, toys and cultural items-such as drums, rocking ravens, orcas and keepsake boxes.

This program is a partnership between Correctional Service Canada (Pacific Region), the Tsilhqot'in National Government, their communities and the Punky Lake Wilderness Camp Society.

Work to Give is based on a recognition that Canada's colonial history, policies and practices have led to the significant overrepresentation of Indigenous people in prisons.

The program acknowledges that:

incarcerated people often have histories of being abused

resilience, rehabilitation and re-offending rates are improved through meaningful work opportunities to give back to communities

This program is trauma and violence-informed because...

It is based on understanding the effects of violence and interrelationships among different structural forms of violence

It fosters indirect opportunities for increased collaboration and connections between the men and communities

Emergency Room Care
Collaborating with Indigenous communities to create a welcoming environment
An Australian emergency room (ER) that serves a large suburban area is making a commitment to provide equitable, respectful care to all patients, including the Indigenous communities they serve.

As a step toward reconciliation, ER leaders hope that this process will help to develop meaningful relationships with the Indigenous communities they serve.
This program is trauma and violence-informed because...

It is part of an effort to create an emotionally safe environment

It also has potential to foster increased collaboration and connections between service providers and Indigenous leaders and communities

Principle 4-Provide strengths-based and capacity-building approaches to support client coping and resilience

Treatment Program
Addressing structural violence for Inuit people through collective healing
Mamisarvik Healing Centre in Ottawa is the only Inuit-run residential trauma and addictions treatment program in Canada and addresses trauma within Inuit healing approaches. The word Mamisarvik means, A Place of Healing.

Mamisarvik clients say that the collective experience of reconstructing their shared histories is healing.

Health Promotion
Trauma-sensitive yoga supports positive body movement in safe spaces
Yoga Outreach is a non-profit organization in British Columbia which trains volunteers to offer strength-based, trauma-sensitive yoga programs for people without resources who otherwise would be unable to participate. Its work is inspired by research conducted by the Trauma Center at the Justice Resources Institute.

In trauma-sensitive yoga, teachers adapt how they lead their classes to help participants build a sense of safety and control over their bodies. This approach is particularly important for people who have 'disassociated' from their bodies after experiences of violence and trauma.

There are no physical assists or touching in trauma-sensitive yoga. To minimize visual triggers, the lights are kept on, curtains are drawn and there are no mirrors. Teachers stay on their mats to avoid 'lurking above' participants. Rather than offer direct instruction such as, "Put your hand on your hip," teachers offer an invitation to participants by saying, "If this feels good for you, I invite you to put your hand on your hip."

References and resources

Guides

Trauma- and violence-informed care: A tool for health and social service organizations and providers
Equip Health Care: Research to Equip Primary Health Care for Equity (University of British Columbia, University of Victoria, University of Northern British Columbia, Western University)

Trauma-informed Practice Guide
BC Centre of Excellence in Women's Health

Trauma-informed: A resource for service organizations and providers to deliver services that are trauma-informed
Klinic Community Health Centre

Books and journal articles

Browne, A.J., Varcoe, C., Ford-Gilboe, M. & Wathen, N. (2015). EQUIP Healthcare: An overview of a multi-component intervention to enhance equity-oriented care in primary health care settings. International Journal for Equity in Health, 14, 152.

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

Elliot, D.E., Bjelajac, P., Fallot, R.D., Markoff, L.S. & Reed, B.G. (2005). Trauma-informed or trauma-denied: principles and implementation of trauma-informed services for women. Journal of Community Psychology 33 (4), 461-477.

Green, B.L., Saunders, P.A., Power, E., Dass-Brailsford, P., Bhat Schlbert, K., Giller, E., Wissow, L., Hurtado-de Mendoza, A., & Mete, M. (2015). Trauma-informed medical care: CME communication training for primary care providers. Family Medicine, 47 (1), 7-14.

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

Hopper, E.K., Bassuk, E.L. & Oliver, J. (2010). Shelter from the storm: Trauma-informed care in homelessness services settings. The Open Health Services and Policy Journal 3, 80-100.

Kirmayer, L. (2013). Embracing uncertainty as a path to competence: Cultural safety, empathy, and alterity in clinical training. Culture, Medicine & Psychiatry, 6, 365-372.

Middleton, J.S. & Potter, C.C. (2015). Relationship between vicarious traumatization and turnover among child welfare professionals. Journal of Public Child Welfare, 9 (2), 195-216.

Ponic, P., Varcoe, C. and Smutylo, T. (2016). Trauma- (and violence-) informed approaches to supporting victims of violence: Policy and practice considerations. Victims of Crime Research Journal, 9, 3-15.

Poole, N. & Greaves, L. (Eds). (2012). Becoming Trauma Informed. Toronto: Centre for Addiction and Mental Health.

Raja, S., Hasnain, M., Hoersch, M., Gove-Yin, S. & Rajagopalan, C. (2015). Trauma informed care in medicine: Current knowledge and future research directions. Family and Community Health, 38 (3), 216-236.

Savage, A., Quiros, L., Dodd, S. & Bonavota, D. (2007). Building trauma informed practice: appreciating the impact of trauma in the lives of women with substance abuse and mental health problems. Journal of Social Work Practice in the Addictions, 7(1-2), 91-116.

Strand, V., Popescu, M., Abramovitz, R. & Richards, S. (2015). Building agency capacity for trauma-informed evidence- based practice and field instruction. Journal of Evidence-Informed Social Work, 13(2), 1-19.

Van der Kolk, B. (2000). Posttraumatic stress disorder and the nature of trauma. Dialogues in Clinical Neuroscience 2 (1), 7-22.

van Mol, M., Erwin, M.C., Kompanje, J.O., Benoit, D.D., Bakker, J. & Nijkamp, M.D. (2015). The prevalence of compassion fatigue and burnout among healthcare professionals in intensive care units: A systematic review. PLoS ONE, 10 (9), 1-22.

Varcoe, C. & Browne, A.J. (2015). Culture and cultural safety: Beyond cultural inventories. In Fundamentals: Perspectives on the Art and Science of Canadian Nursing. C. D. Gregory, L. Raymond- Seniuk, L. Patrick and T. Stephen (Eds.), 216-231. Philadelphia: Lippincott Williams & Wilkins.

Watt, M. E. & Scrandis, D.A. (2013). Traumatic childhood exposures in the lives of male perpetrators of female intimate partner violence. Journal of Interpersonal Violence, 28 (14), 2813-2830.

Glossary

Definitions related to violence

Violence is the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, which either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation.

Interpersonal violence refers to violence between individuals, and is subdivided into family and community violence. Family violence includes child maltreatment; intimate partner violence; and elder abuse. Community violence includes acquaintance and stranger violence, youth violence; violence related to property crimes; and violence in workplaces and other institutions.

Collective violence refers to violence committed by larger groups of individuals and can be subdivided into social, political and economic violence.

Self-directed violence refers to violence in which the perpetrator and the victim are the same individual and is subdivided into self-abuse and suicide.

Systemic violence is violence perpetrated against people through systems often as a result of widespread beliefs and socio-political systems, for example, ethnic-based genocide such as the Holocaust, the colonization of Indigenous peoples, or the normalization of gender-based sexual violence. The terms systemic and structural violence are often used interchangeably.

Definitions related to trauma

Trauma is both the experience of, and a response to, an overwhelmingly negative event or series of events, such as interpersonal violence, personal loss, war or natural disaster. In the context of violence, trauma can be acute (resulting from a single event) or complex (resulting from repeated experiences of interpersonal and/or systemic violence).

Historical trauma refers to the ways in which political processes and systemic violence (such as the Holocaust or forced relocations of Indigenous people) impact individual experience, and in turn the effects of individual experiences on those political processes. Some researchers suggest that the idea of historical trauma has been used both to recognize the impact of historical violence on Indigenous people and to pathologize Indigenous people.

Intergenerational trauma refers to the ways that multiple generations are impacted by trauma both through the effects of one generation of people on the next, as well as by the ongoing conditions in which people live.

Other related definitions

Resilience is a dynamic process that enables an individual to develop, maintain, or regain their health and well-being despite experiences of significant adversity or trauma. Resilience is developed through a range of individual (i.e. psychological, biological) and environmental (i.e., social, political, and cultural) factors that can help people positively adapt to difficult life circumstances.

Endnotes

Endnote i

Endnote ii

Endnote iii

Endnote iv

Endnote v

Bethell, C.D., Newacheck, P., Hawes, E., & Halfon, N. (2014). Adverse childhood experiences: Assessing the impact on health and school engagement and the mitigating role of resilience. Health Affairs, 33(2), 106-2115.

Lamers-Winkelman, F., Schipper, J.C.D, & Oosterman, M. (2012). Children's physical health complaints after exposure to intimate partner violence. British Journal of Health Psychology, 17, 771-784.

Bombay, A., Matheson, K., & Anisman, H. (2011). The impact of stressors on second generation Indian residential school survivors. Transcultural Psychiatry, 48, 367-391.

Felitti, V.J., & Anda, R.F. (2010). The Relationship of Adverse Childhood Experiences to Adult Health, Well-being, Social Function, and Healthcare. Cambridge: Cambridge University Press.

Endnote vi

Brownridge, D. A. (2008). Understanding the elevated risk of partner violence against Aboriginal women: A comparison of two nationally representative surveys of Canada. Journal of Family Violence, 23(5), 353-367.

Brownridge, D. A., Ristock, J., & Hiebert-Murphy, D. (2008). The high risk of IPV against Canadian women with disabilities. Medical Science Monitor, 14(5), 27-32.

Endnote vii

Mihorean, K. (2005). Trends in self-reported spousal violence. In K. AuCoin (Ed.), Family violence in Canada: A statistical profile 2005. Ottawa, Canada: Canadian Centre for Justice Statistics, Statistics Canada, 13-32.

Tjaden, P., & Thoennes, N. (2000). Prevalence and consequences of male-to-female and female-to-male intimate partner violence as measured by the National Violence against Women Survey. Violence against Women, 6, 142-161.

Endnote viii

Endnote ix

Endnote x

Endnote xi

Ansara, D., & Hindin, M. (2010). Exploring gender differences in the patterns of intimate partner violence in Canada: A latent class approach. Journal of Epidemiology and Community Health, 64, 849-854.

Nybergh, L., Enander, V., & Krantz, G. (2016). Theoretical considerations on men's experiences of intimate partner violence: An interview-based study. Journal of Family Violence, 31, 119-202.

Endnote xii

Endnote xiii

Endnote xiv

Endnote xv

Endnote xvi

Endnote xvii

Endnote xviii

Endnote xix

Endnote xx

# data[].attributes.attachment_link.title
Trauma and violence-informed approaches to policy and practice

# data[].attributes.attachment_link.description
Trauma-informed approaches are familiar to many organizations and service providers. Recently, this term has been expanded to include "and violence", an important change in the language which underscores the connections between trauma and violence. Trauma and violence-informed approaches are policies and practices that recognize the connections between violence, trauma, negative health outcomes and behaviours.

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Several levels of government and social service agencies failed to take action to protect people labelled/with intellectual disabilities.

The lack of resources outside of the institution forced individuals inside where they experienced years of violence.

While there has been progress, our research has shown that the cycle of systematic trauma has yet to be repaired.

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Image description:  Yellow sun drawing on white background. Rays are yellow lines pointing out from circle. Face in middle with squiggly line as mouth. Heart nose and circle as eyes with arched eyebrows.

We thank all of the authors who created the resources that allowed us to create gather the information listed here. We would like to acknowledge Thelma Wheatley, author of "And Neither Have I Wings to Fly."

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In recent years, we have learned a lot about violence in large scale institutions, both past and present.

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For example, patients at Huronia Regional Centre reported being punched, cuffed, kicked, having their heads bashed against a wall, or shoved down a toilet bowl (Wheatley, 2013).

In 1956, a government inspector examined Huronia and found three padlocks under a patient’s mattress and metal knives (Wheatley, 2013).

The Willard Report of 1976, commissioned by the government of Ontario, found  reports of a murder committed by a former patient, and a horrific rape and murder of a patient in the 1970s (Wheatley, 2013).

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Image description: Red letters on white background read "lock side room hurts." Drawing of sad face at bottom of page.