Trauma-Informed Care Empowering. Engaging. Effective. Joann Stephens Stable Life, Inc.

1. Trauma-Informed Care Empowering. Engaging. Effective. Joann StephensStable Life, Inc.

2. Trauma-Informed Care What it is:a philosophical shift What it is not:an intervention to address PTSD **************************************** What happened to you? vs. What’s wrong with you?

3. Statistics, or “How bad is it, really?” 56% of the general population reported at least one traumatic event(Kessler,1995) 90% of mental health clients have been exposed to a traumatic event and most have multiple experiences of trauma(Muesar, 1998) 83% of females and 32% of males with developmental disabilities have experienced sexual assault. (Hard, 1986) Of those who were assaulted, 50% had been assaulted 10 or more times(Sobsey and Doe, 1991)

4. Psychological Trauma - What is it? Trauma refers to extreme stress (e.g., threat to life, bodily integrity or sanity) that overwhelms a person’s ability to cope. The individual’s subjective experience determines whether or not an event is traumatic. Traumatic events result in a feeling of vulnerability, helplessness and fear. Traumatic events often interfere with relationships and fundamental beliefs about oneself, others and one’s place in the world. (Giller, 1999; Herman, 1992)

5. Psychological Trauma - Examples Violence in the home, personal relationships, workplace, school, systems/institutions, or community Maltreatment or abuse: emotional, verbal, physical, sexual, or spiritual Exploitation: sexual, financial or psychological Abrupt change in health, employment, living situation over which people have no control Neglect and deprivation War or armed conflict Natural or human-caused disaster

6. Mediating or Exacerbating Factors Person Age / developmental stage Past experiences and coping skills Cultural beliefs Environment Presence of sensitive caregiver Supportive response Culture and cultural beliefs Event Severity & chronicity Interpersonal vs. act of nature Intentional vs. accidental

7. Acute Trauma – PTSD / Acute Stress Disorder • Re-experiencing - disturbing memories, dreams, flashbacks, intense psychological or physiological distress • Avoidance/ Numbing -avoidance of thoughts, feelings, people, places, & activities; feelings of detachment and amnesia; sense of a limited future • Arousal - irritability, angry outbursts, difficulty concentrating, hyper-vigilance, increased startle response, sleep problems

8. Complex Trauma / Complex PTSD / Developmental Trauma Disorder Result of traumatic experiences that are interpersonal, intentional, prolonged and repeated

9. Symptoms of Complex Trauma Re-experiencing Avoidance/ Numbing Arousal PLUS • Emotional difficulties:managing feelings; chronic anxiety; empathizing; low frustration tolerance; expressing needs, thoughts, concerns using words • Cognitive difficulties: cognitive biases; understanding what is being said; doing things in logical sequence; seeing ‘gray’; working with time; multiple ideas simultaneously; maintaining focus • Social difficulties: attending to or accurately assessing social cues; connecting with others; seeking attention in appropriate ways; appreciating how behavior impacts others • Handling transition and change: impulsive; adapting to change; handling unpredictability, ambiguity, uncertainty & novelty

10. Sanctuary Trauma The overt and covert traumatic events that occur in various settings: • mental health & substance abuse services • foster care • corrections • medical • educational • religious • workplace

11. “I had been coerced into treatment by people who said they were trying to help…These things all re-stimulated the feelings of futility, reawakening the sense of hopelessness, loss of control I experienced when being abused. Without exception, these episodes reinforced my sense of distrust in people and the belief that help meant humiliation, loss of control, and loss of dignity.”

12. Vicarious or Secondary Trauma The experience of learning about another person’s trauma and experiencing trauma-related distress as a result of this exposure

13. Adverse Childhood Experience (ACE) Study http://www.acestudy.org/ http://www.cdc.gov/nccdphp/ACE/

14. Abuse Psychological (by parents) Physical (by parents) Sexual (anyone) Physical neglect Emotional neglect Household with: Substance abuse Mental illness Separation/divorce Domestic violence Imprisoned household member ‘ACE’

15. ACE Score = Trauma “Dose” Number of individual types of adverse childhood experiences were summed… ACE scorePrevalence 0 32% 1 26% 2 16% 3 10% 4 or more 16%

16. As ACEs , problems : • alcoholism and alcohol abuse • illicit drug use • risk for intimate partner violence • eating disorders • multiple sexual partners • smoking • suicide attempts • chronic obstructive pulmonary disease (COPD) • depression • ischemic heart disease (IHD) • liver disease • sexually transmitted diseases (STDs) • obesity • health-related quality of life

17. Impact of Trauma Over the Life Span Effects of childhood adverse experiences: • neurological • biological • psychological • social

18. Beginning to Understand‘Disrupted Neurodevelopment’ • Fight: resist • Flight: run away • Freeze: stay still

19. The Stress Response and the Brain If there is danger the ‘thinking brain’ shuts down, allowing the doing brain to act.

20. Autonomic and Parasympathetic Nervous System • Increase HR and blood pressure • Tunnel vision • Event recorded in “high definition” • Increased cholesterol • Pain sensation dulled – natural morphine (endorphins) • Increased alertness, increased focus • Insulin increases • Memory loss from parts of the event • Increased strength, energy, aggression • Hearing may shut down • Time slows down or speeds up (Susan A. Storti, 2008)

21. Immediate Aftermath of Abuse What you may see: Nothing Laughter Shut down / numb Others? What you may not see: Confusion Guilt / Shame Fear Others?

22. Potential Triggers Lack of control-powerlessness Threat or use of force Observing threats, assaults, others engaged in self-harm Isolation Physical restraints – handcuffs, shackles Interacting with authority figures Fear based on lack of information Lack of privacy Removal of clothing – strip searches, medical exams Being touched – pat downs Being watched – suicide watch Loud noises Darkness Intrusive or personal questions Being in a locked room Institute for Health and Recovery

23. R E e Past Present E - A Large Event e - A Small Event R - A Large Reaction

25. Complex Trauma – Impact on Development

26. Impact on WorldviewTypical Development vs. Developmental Trauma Nurturing & stable attachments with adults Belief in a predictable & benevolent world/ generally good things will happen to me Feeling of positive self-worth /others will see my strengths Optimism about the future Feeling that I can have a positive impact on the world Basic mistrust of adults/inability to depend on others Belief that the world is an unsafe place/bad things will happen & they are usually my fault Assumption that others will not like me Fear & pessimism about future Feelings of hopelessness & lack of control

27. Understanding Behaviors: Explanation vs. Excuse • External defense • Anger / defiance • Violence towards others • Truancy • Criminal acts • Internal defense • Withdrawal • Substance use • Eating Disorders • Violence to self • Dissociation

28. Reenactment Behaviors Certain behaviors can cause caregivers to feel negative and hopeless about the person they work with People generally do not consciously choose to repeat the patterns of painful relationships Are familiar and have helped in the past ‘prove’ the person’s negative beliefs Help vent frustration, anger and anxiety Give a sense of mastery over the old traumas

29. Shame and Humiliation The basic psychological motive or cause of violent behavior is the wish to ward off or eliminate the feelings of shame and humiliation – a feeling that is painful and can even be intolerable – and replace it with a feeling of pride” (Gilligan, 2004)

30. Impact of Trauma on World View The world / environment is unsafe Other people are unsafe and cannot be trusted My own thoughts and feelings are unsafe I expect crisis, danger and loss I have no self-worth and no abilities

31. Our labels don’t describe the complex interrelated, physical, psychological, social, and moral impacts of trauma …and they rarely help us know what to do to help.-- Bloom • Dissociative Disorder • Somatoform Disorder • Anxiety Disorder • Major Depression • Borderline Personality Disorder • Substance Abuse Disorder • Post Traumatic Stress Disorder • Attention Deficit Hyperactivity Disorder • Conduct Disorder • Bipolar Disorder • Attachment Disorder • Autistic Disorders

32. Trauma-Informed Care – What is it? Incorporate knowledge about trauma – prevalence, impact, and recovery – in all aspects of service delivery Place priority on: • meaningful consumer engagement • physical and emotional safety • choice • collaboration / sharing power • empowerment and skill building • healing relationships Increase caregiver capacity

33. Guiding Values of Trauma-Informed CareHealing Happens in Relationship

34. What does it look like? Traditional • Key Question: ‘What’s wrong with you?’ • Service providers are the experts on the lives of consumers • Therapy sessions and specific interventions are viewed as the primary method of treatment Trauma- Informed • Key Question: ‘What has happened to you?’ • Consumers are the experts on their lives and benefit from a partnership with providers • Healing happens in healthy relationships

35. Comparison of Systems (cont’d) Traditional • Decreasing symptoms viewed as success • Rules, directives, and use of token systems as primary approaches to maintaining order Trauma-Informed • Symptoms viewed as adaptations and ways to cope to trauma. Healing process may temporarily worsen symptoms • Motivational interviewing, lower brain interventions, and compassionate communication are tools used to maintain healing relationships

36. Practice Based on TIC ValuesValue: Pursue the person’s strengths, choice and autonomy TRADITIONAL 1. Everyone goes to bed at 10:30 pm and lights out 2. Person is given completed treatment plan which must be signed for services 3. A few homogenous activities are provided and everyone is supposed to attend TIC 1. A range for bedtime that identifies and adapts to individuals difficulty with night-time, bedrooms, and different bio-rhythms 2. Recovery plans are created collaboratively; family members or advocates are included if the consumer so chooses 3. A variety of activities are offered and consumers are provided a menu of options based on needs, desires and recovery plan

37. General Tips Think about the possibility of trauma as underlying problem – helps to diminish frustration History of physical violations may create hypersensitivity about bathing, changing clothes, physical exams - do what’s possible to help people feel in control Recognize issue of trust and betrayed trust will be a major, ongoing issue If you cannot understand why someone does or doesn’t do something that seems to be common sense, be curious (Bloom, 2009)

38. Outcomes • Greater consumer satisfaction • Increased recovery rates • Reduced consumer retraumitization • Lower rates of consumer and staff assault and injury • Lower rates of staff turnover and higher morale Sources: • Pennsylvania State Hospitals • Massachusetts Dept. of Mental Health • Fallot & Harris, Using Trauma Theory to Design Service Systems • Mendota Mental Health Institute, Wisconsin

39. Sample of Models, Guides and Resources The Anna Institute. http://www.annafoundation.org/ Developing Trauma-Informed Organizations, Inst. for Health and Recovery. http://www.healthrecovery.org/ Risking Connection, Sidran Institute. http://www.riskingconnection.com/ The Sanctuary Model, CommunityWorks. http://www.sanctuaryweb.com/ Using Trauma Theory to Design Service Systems, Community Connections.

40. Credits • Sandra Bloom, Creating Sanctuary • Roger Fallot & Maxine Harris, Using Trauma Theory to Design Service Systems • Charles Figley, Compassion Fatigue • Esther Giller, Sidran Foundation • Judith Herman, Trauma and Recovery • Bruce Perry, http://www.childtrauma.org/ Multiple slides were taken from the work of… • National Center for Trauma Informed Care, http://mentalhealth.samhsa.gov/nctic/ • Roger Fallot, Wisconsin TIC presentations • Vince Fellitti and Rob Anda (ACE study)

41. Contact Information Elizabeth Hudson, LCSW Trauma-Informed Care Consultant WI Dept. of Human Services Division of Mental Health and Substance Abuse Services 608-266-2771 Elizabeth.Hudson@wisconsin.gov Employed by University of Wisconsin - School of Medicine and Public Health