Trauma Repair

How brain science is changing social service delivery— the CUPS example

By Tadzio Richards

We were seeing people come back or simply not get better,” says Robert Perry. “And then along comes the brain science and it was like holy-oley! This seems to explain it. It’s not just poverty, it’s trauma—trauma brought about in the early years that has shaped you, not only your self but your brain as well.”

Perry is a senior director at the Calgary Urban Project Society (CUPS), a non-profit organization founded in 1989 to “help people overcome poverty.” In September 2018 he was part of a press conference at the two-storey CUPS building in Calgary’s Beltline district just south of downtown. Alberta’s Minister of Health, Sarah Hoffman, and Joe Ceci, the Minister of Finance, were at that media event to announce a $1.4-million, three-year funding grant to CUPS to give low-income and homeless Calgarians faster access to the organization’s mental health and addiction supports and other social services.

Among the speakers that day was Karrie Thibodeau, a CUPS client. “Before I came to CUPS, back in 2015, I was broken in a lot of ways,” she said, standing in front of the politicians. “I used to be a social worker, I had a really good job, and some traumas happened in my life. I was on the verge of being hospitalized almost every day. I’ve struggled with depression most of my life and then I was diagnosed with complex PTSD [post-traumatic stress disorder]. But thanks to the care of the mental health team—my doctor at CUPS, my social worker, the counsellor that’s here, my psychiatrist here, the staff, I’m learning to get my life back on track.” She gripped the podium as she spoke. “I was one of those people on the waiting list,” she said. “If I had to wait longer I don’t know if I would be here today.”

When Thibodeau first came to CUPS they were initiating a wholesale change within the organization—moving away from a piecemeal, reactive approach to delivering services, and towards more holistic, trauma-informed and integrated care. The change is inspired by research on trauma and brain development at the Center on the Developing Child at Harvard University. The Harvard centre receives funding from the Alberta Family Wellness Initiative (AFWI)—founded in 2007 by the private, Calgary-based Palix Foundation. AFWI also funds a 30-hour online “Brain Story Certification” course that aims to give professionals and the lay public alike “a deeper understanding of brain development and its consequences for lifelong health.” The course is part of a larger project of “intentionally infusing brain science research findings” into social service, education and healthcare programs and organizations in Alberta and beyond.

CUPS is one of those organizations. In conversation, Perry says understanding early brain development helps staff better respond to people who come in for help. That’s a key step, he says, but organizational change remains “a big work in progress.” In 2015 “we were in a joint work group [Change In Mind] with 10 groups in the US and five in Alberta, including ourselves,” he says. “We all got together and the argument that we had—a lot of Harvard folks were there—was: The why is clear, it’s how do we do it? What do you change? What do you stop doing? And what do you start doing?”

Social service delivery at CUPS is now more “trauma-informed.” Instead of asking “What’s wrong with you?” they ask “What happened to you?”

Thibodeau describes CUPS as “a one-stop shop where you can go and you can feel safe.” That’s not how social services are often talked about in Alberta. In 2015 a provincial government report, “Valuing Mental Health,” said that “many Albertans described the addiction and mental health system as a patchwork of programs—often fragmented, sometimes duplicated, and with gaps in service” that “can be devastating.” A 2019 report from The School of Public Policy at the University of Calgary says that while Alberta has 20,000 different social and community services provided by non-profit agencies and the provincial government, they constitute a “confusing jumble” and a “broken system” in need of “full-scale transformation.”

CUPS can be seen as a microcosm of that system. For starters, it was created during government austerity in the 1980s and ’90s, when cuts to government-run institutions, as University of Calgary researchers wrote in a 2018 paper, were “accompanied by levels of funding that simply weren’t enough to provide all the resulting community services needed.”

Churches and charities moved into the gap. In Calgary, CUPS was formally established in 1989 as an ecumenical project to “provide referral services and basic medical care” to people arriving at the doors of downtown churches in search of help. By 2018 CUPS was serving more than 11,000 people a year and had received over $15.6-million in funding, roughly half from government programs and grants and the rest from charitable donations.

Today CUPS programs help people who are homeless or at high risk of homelessness to find housing or to get emergency funding. Family health, mental health, primary care and dental programs are offered at in-house clinics, and CUPS also provides healthcare assistance to six Calgary shelters. As well, they offer parenting skills classes for adults and run the One World Child Development Centre—an all-day daycare and “nurturing educational environment” for young children from low-income families.

Early life experiences build “brain architecture,” akin to laying a house foundation. Attentive engagement nurtures coping skills, emotional control and the ability to form strong relationships; toxic stress can do the opposite.

That’s a lot of programs. But CUPS administrators say those services, particu-larly until recently, were delivered with “a band aid approach.” Help was usually given for one issue at a time, often in isolation from other things going on with a client, and the agency, partly because of being overwhelmed without the capacity to meet the demand, did little follow-up. Staff did “enough to address the immediate crises” and were “good at getting families and individuals stable,” but that stability often didn’t last.

Those problems mirror the challenges in the broader “broken system.” Isolated service delivery is a result of fragmented and often duplicated program funding. In the absence of strong government funding and policy support for integration, the Alberta social services system has no cohesion; it’s empty at the centre. What’s also missing is a unifying guide to steer organizational change toward better client outcomes. At CUPS, Perry and others say that kind of “change catalyst” is now emerging from brain science.

Scientists have long known that “traumatic stress” harms the brain. PTSD in combat veterans, for instance, was described before the First World War, though the condition, or cluster of symptoms, didn’t get official diagnostic recognition until 1980. When it comes to such recognition, domestic life lags behind war, as usual, but it does come. Bessel van der Kolk, director of Boston’s Trauma Research Foundation, wrote in 2014: “War is not the only calamity that leaves human lives in ruins…. For many people the war begins at home.”

Trauma, it turns out, afflicts the majority of us. Just how common it is was revealed by a landmark 1998 study in California. The Adverse Childhood Experiences (ACEs) study measured the prevalence of 10 types of trauma experienced in the home before age 18. In a study population of over 17,000 mostly college-educated, mostly white people with jobs and healthcare coverage, 64 per cent had an ACE score of at least 1, meaning they had suffered at least one kind of traumatic stress such as physical, emotional or sexual abuse; physical or emotional neglect; or household dysfunction such as substance abuse in the home, violence against the mother, divorce, an incarcerated close relative or caregiver mental illness. Twelve per cent of people had an ACE score of four or higher. Researchers found that the higher the score the higher the risk of harmful physical and mental health conditions as adults. A person with a score of four, for instance, is “twice as likely to have heart disease and cancer, seven times more likely to be addicted to alcohol and 12 times more likely to attempt suicide.”

The ACEs questionnaire didn’t count stresses such as racism or community violence or the trauma of poverty, so it’s not comprehensive. Neither is it a diagnostic tool. But the California ACEs study—later replicated to nearly identical results in Alberta—does show that the majority of people in North America experience early life traumatic stress that can contribute to serious health challenges as adults.

The insight that experience shapes our brains, for better or worse, is central to what’s now called the “core story” of brain development. In a 2014 paper, “A Decade of Science Informing Policy,” Harvard researchers said the “core story” was developed in the US because scientists were “increasingly disturbed by the gap between their research on early development and the reality that too many young children—especially those facing adversity—were not being well served by existing policies.”

From research in diverse fields, scientists knew the monster in the room, so to speak, is stress. Not “good” stress—an exam or the first day of school, for instance—where the heart drums faster and stress hormones surge but the body quickly returns to normal. The problem is bad stress that goes on and on. The causes are many—take your pick among traumas—but the result is the same: The body goes into red alert mode and “pumps out adrenaline and cortisol continuously.” If this goes on for months or years, the heart and circulatory and immune systems are weakened, and the fine balances of health and sanity begin to fray.

“If you’re chronically stressed and then experience an additional traumatic event,” writes one researcher, “your body will have trouble returning to a normal state. Over time, you will become more sensitive to trauma or stress, developing a hair-trigger response to events that other people shrug off…. Childhood trauma is biologically embedded in our bodies.”

New brain research can shift understanding of how and why people end up with positive or negative life outcomes. But until recently it was entangled in academic jargon; it wasn’t a story the public could easily understand. Thus the Harvard centre has worked with the Frameworks Institute, a US group that helps academics and non-profits communicate to the public.

Nancy Mannix, chair and patron of the Palix Foundation, has been trying to bridge that gap. In November 2018 she told a packed ballroom of social services, education and healthcare practitioners in Calgary’s Hyatt Regency that Frameworks starts by asking the general public “What makes a good outcome or a bad outcome for a child?”

They report three commonly held “dominant” beliefs, she said. The first is that a child is an “empty vessel” with good or bad parents and the child can’t help but turn out just like the parents. The second is that the fate of a child is fixed by its DNA “and there’s nothing you can do about it,” said Mannix. “And the third explanation, which is the killer, is that it’s all about character and will power, pull yourself up by your bootstraps and overcome adversity with your personal choices.”

“None of those are correct,” she said. In contrast, the “innovation” that Frameworks and Harvard researchers came up with, she said, is a “core story” that uses metaphors to communicate the science of brain development. As Mannix explains it: Early experiences in life build “brain architecture,” akin to laying the foundation of a house. The building blocks of early brain development are formed through a “serve and return” dynamic between a child and an adult caregiver. A relationship of attentive engagement nurtures healthy development, which leads to good coping skills, emotional control and the ability to plan and form strong, stable relationships with others. But “toxic stress” can do the opposite. In the absence of “buffering protection,” such as having at least one supportive adult, severe and ongoing traumatic stress can impair executive functioning and cause “long-lasting wear and tear” on the body and brain.

The good news is the brain is “plastic” and can heal. As Nicole Sherren, scientific director for AFWI, says, if toxic stress can be replaced with practices that “build resilience, in the same way you would build healthy brain architecture through supportive relationships,” some stress-induced damage can repair over time.

The “core story” is the basis for AFWI’s online Brain Story certification course. Over 21,000 people have enrolled, including 14,000 in Alberta. At CUPS nearly all staff have completed the course. Lara Higgins, director of integrated services at CUPS, says the “brain story” has explanatory power. “When [a client] comes into the waiting room and lashes out at people around them or lashes out at the medical office assistants,” she says, “first of all it’s stress and anxiety and the environment they’re living in—the DI [Calgary Drop-In Centre] maybe, not a nice place, no one wants to be there—but then, also, if you didn’t grow up in a loving, stable, consistently stimulating and nurturing home environment, you don’t walk into the [CUPS] waiting room going ‘Oh, all these people are here to help me.’ That’s just not your experience in life.”

“Imagine that you don’t grow up with a trusting, stable parent,” she says. “If they have mental health issues, they’re not focusing on the child, not because they don’t love the child [but because] they don’t have the ability at that time to give the child focused attention. Maybe they’re worried about paying the rent, they’ve moved 10 times, they have no food. Mom or dad are worrying about surviving and the child is neglected—if that’s your experience, do you expect your teacher at school to be caring and kind? If you’ve not experienced [kindness], you go out into the world mistrusting everybody. The brain develops in very systematic ways, and crucial in those first three to six years is your ability to self-regulate and handle your emotions. If you can’t—if you’re triggered all the time and you’re scared all the time—you don’t go to school in a headspace to learn or connect with anyone and everything just perpetuates.”

Higgins says social service delivery at CUPS is now more “trauma-informed.” In part this means that instead of asking “What’s wrong with you?” they now ask “What happened to you?” The difference is that while the first question “leads to fixes that are important but temporary: a loan, a medical treatment, a roof for the night,” the latter question turns the focus to “addressing trauma and building resilience.” Improving social services, says Higgins, begins with that change in perception. “Changing culture and a shift in philosophy is really difficult. But if you don’t start changing the narrative and you don’t start asking and getting a full picture of what’s going on, you stigmatize trauma,” she says. “It’s definitely been an evolution in the way we look at the folks that come in.”

In the past, she says, each program at CUPS was in a silo. Each organizational silo had its own paperwork. Three computer databases were in use at CUPS and the systems could not communicate. If a person came in the doors seeking help for more than one issue they went from intake desk to intake desk, telling their story again each time. That caused triggering stress for already traumatized people.

“The women’s health desk was here and the family development centre desk was there,” says Higgins, placing her hands side by side. “We operated on the philosophy of ‘If someone comes in asking for something, let’s just give them that,’ so they’d stand at the women’s health desk, they’d get registered, they’d go see a doctor, they’d give all their information, sign their consent form, and then they’d say ‘Oh, I need some winter coats for the kids.’ They’d be told, ‘OK, go to that other desk,’ and there we’d say ‘What’s your name?’ And they’re, like, ‘I just gave it to her.’ And [staff] could talk to each other, we could see each other, but we would have to say to the client ‘I’m going to ask you again—what’s your date of birth? We use different computer systems and we’re going to get you to sign another consent form.’ ”

Trauma-informed care implies a different approach. As the authors of the Alberta government’s “Valuing Mental Health” report wrote in 2015: “A system that is welcoming, respectful, compassionate and caring reduces stigma and is an important part of the healing process. The challenge, then, is to provide a more coordinated and integrated system that is easily accessible…. The system should provide appropriate screening, a clear path of care, and strong data collection to ensure services are working well.”

CUPS executive director Carlene Donnelly says they didn’t start from scratch when implementing change in that direction. Back in 1999, she says, a “focus group with our families and individual participants” found that parents at CUPS wanted more resources to go into early childhood development. To support that, Donnelly got funding from Mannix and her foundation to start the One World Child Development Centre in 2002. It began as a way to “find some social encounters” for the children and “get them ready to enter the school system,” says Donnelly, but evolved into a program that today combines “educational and therapeutic components… into a systematic, planned inter-vention to address a child’s needs during the formative first three to six years of life.” In hindsight, she says, One World “became a pilot for how to apply the brain story in practice.”

But that was just one program. Donnelly says they studied different models of change to see if they could copy what other non-profits had done at the whole-organization level. “None were really user-friendly,” she said. “So we developed our own.”

Internally, instead of seeing CUPS as a place with multiple silos providing housing services or food bank referrals or health services, with minimal connection to the other programs, Donnelly says they had to reconceptualize CUPS as a place that provided integrated care and “integrated outcomes” such as resiliency and “self-sufficiency.” To do that, she says, they had to fix the computer issues to “go from 13 entry points to one entry point, which is what we did.” The process “was very difficult and expensive,” she says, but critical to help ensure that people only have to tell their story once when they first come in.

Now, “in theory,” says Higgins, when someone arrives at CUPS they will get help to alleviate an immediate stress, but they’ll also get a chance to sit with a staff member and have a “holistic conversation” about what else is going on. The information is recorded in the CUPS resiliency matrix. That sounds bureaucratic but is pretty simple. The staff member asks how a person is doing in 13 areas (12 if no kids), broadly grouped under “economic,” “social-emotional” and “health” domains. Each subdomain, such as family relations, mental health or housing and living conditions, for example, gets a score from one (“in crisis”) to five (“thriving”).

“We use [the resiliency matrix] to build the evolving care plan,” says Higgins. The information serves as a “baseline” shared with other staff such as nurses, a psychiatrist or social worker as care needs dictate over time. The assessment is repeated months later and the difference in scores allows CUPS to measure “the impact we’re having,” she says. “We never had that ability before.”

Still, despite progress, she cautions, “we’re definitely at the beginning…. Our services are co-located and coordinated, but in terms of having a real model of integrated care, that’s what we’re working on. We’re not there yet.”

“Most people we meet with are struggling with pretty heavy situations,” she says. “The shortage of housing, the lack of employment, someone’s choosing between food and a home, it’s so stressful. If there’s something we can’t accommodate here, then we reach out to external agency partners. But then you get into: What [information] can we share? And who ultimately is in control of the care plan? Who’s doing what?”

As an example of how it has worked well, she tells the story of Mike Hrynczak, who came in asking to take a “nurturing parenting” class. In conversation, CUPS staff learned he had four young children with his ex-partner, but she was addicted to drugs and in a new relationship. Hrynczak was the main parent but was losing—and then lost—his drywalling job and his housing. “We got him into subsidized housing,” says Higgins. “Because of a lack of affordable housing units [in Calgary], he was one of the lucky ones.” His children got into the programs at One World, and CUPS helped him get a bursary to go to Bow Valley College. Absent this conversation, “it would have been hard to know what else he needs,” says Higgins. “If you don’t approach it in a holistic way, how do you even know?”

Another CUPS client, Cindy Ryan, tells a similar story. When she first came to CUPS, after moving to Calgary from Red Deer, “I was on so much medication from my doctor in Red Deer,” she says. “At CUPS they thought I was selling medication. I was like ‘No, my doctor put me on all of this.’ They helped me get off a lot of it. I still take an antidepressant. They work with me to regulate my emotions in a natural way, to try and live a positive life. They supported me while I left my abusive ex.”

“If you don’t start changing the narrative and don’t get a full picture of what’s going on, you stigmatize trauma.” – Lara Higgins, CUPS

Her young son too now goes to the One World program, she says. “Before I took him, he was crying and whining. He didn’t know how to express himself [but] they started to teach me to empathize with him and to understand where he’s coming from. Ever since I’ve been doing that it’s been totally working for us. He’s almost a different little kid.”

With those supports in place, Ryan enrolled in courses at Mount Royal University. She continues to work with a CUPS counsellor. “I’m part Indigenous but I was taken from my own mom and raised in a white family,” she says. “Once I started doing counselling, I understood why I was drinking and everything—it had to do with my childhood trauma. I was sexually abused as a child. I was holding on to anger and feeling shameful about it, but you have to talk things through. It’s not my fault an adult preyed on a child. Learning that felt really good and took a lot of weight off my shoulders—my life is getting better.”

Tadzio Richards is associate editor at Alberta Views. Comment on this story:


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