Karen Yost, MA, LSW, LPC, NCC, ALPS, CSOTS, MAC Prestera Center

1. Trauma Informed Care Karen Yost, MA, LSW, LPC, NCC, ALPS, CSOTS, MACPrestera Center

2. Objectives of Training The participant will understand: • Sources of potential trauma and complex trauma for individuals served by child serving systems. • Impact of trauma on emotional and behavioral functioning • Principles of trauma-informed systems. • Ways to decrease the possibility that those seeking services and staff experience trauma.

3. Trauma Defined… • “an emotional shock that creates significant and lasting damage to a person’s mental, physical and emotional growth.” • Traumatic experiences can significantly alter a person’s perception of themselves, their environment, and the people around them. In effect, trauma changes the way people view themselves, others and their world. • Can impact safety, well-being, permanence.

4. Developing Trauma Informed Care This is Anna at age one. This is Anna years later – in a mental institution. What happened?

5. Prevalence • Over 90% of mental health clients have trauma histories • In state hospitals, estimates range up to 95% • 90% or more of women in jails and prisons are victims of physical or sexual abuse • Up to 2/3 of men and women in substance abuse treatment report childhood abuse or neglect • Similar statistics exist for foster care, juvenile justice, homeless shelters, welfare programs, etc • Boys who experience or witness violence are 1000 times more likely to commit violence

6. Vulnerable Populations • Children & women • American Indian/Alaska Native • Veterans • Refugees and immigrants • People who are homeless • People who are institutionalized in mental health or criminal justice systems

7. Staggering Financial Burden of Childhood Abuse & Trauma • Annual Direct Costs: Hospitalization, Mental Health Care System, Child Welfare Service System, Law Enforcement = $33,101,302,133. • Annual Indirect Costs: Special Ed, Juvenile Justice, Mental Health & Health Care, Criminal Justice System, Lost Productivity = $70,652,715,359. • Total Annual Cost: $124 billion. Economic Impact Study. (September, 2008). Prevent Child Abuse America

8. Trauma is… • NOT a diagnostic category • There is no universal definition of trauma. It is defined by the person who has had the experience. • An experience or series of experiences that elicits feelings of terror, powerlessness, & out-of-control psychological arousal; result in survival driven behaviors, thoughts, emotions, & needs.

9. Trauma… • Often misinterpreted & assigned as symptoms of disorders (depression, Bipolar Disorder, ADHD, Oppositional Defiant Disorder, Conduct Disorder, Attachment Disorder, etc.) • These diagnoses generally do not capture full extent of developmental impact of trauma.

10. Exposure to Trauma • Trauma can be: • A single event • A connected series of events • Chronic lasting stress Trauma is under-reported and under-diagnosed. (NTAC, 2004)

11. Types of Traumatic Experiences • Loss of a loved one • Abandonment • Accidents • Homelessness • Community/school violence • Bullying, including cyber-bullying • Domestic violence • Neglect • Frequent moves • Serious medical Illness • Physical abuse • Sexual abuse • Emotional/verbal abuse • Man-made or natural disasters • Witnessing violence • Terrorism • Refugee and War Zone trauma. 

12. Types of Trauma A single traumatic event that is limited in time. The experience of multiple traumatic events. Vicarious Trauma Both exposure to chronic trauma, and the impact such exposure has on an individual. The traumatic removal from home, admission to a detention or residential facility or multiple placements within a short time.

13. Trauma can occur at any age. Trauma can impact anyone.

14. ACES Pyramid Bridging the gap between childhood trauma and negative consequences later in life. • 50% of study participants reported at least one adverse childhood experience • 25% reported at least two or more untreated trauma

15. Adverse childhood experiences increase the risk of: 4 or more traumatic experiences shorten life expectancy by 20 years

16. Adverse childhood experiences increase the risk of: 4 or more traumatic experiences shorten life expectancy by 20 years

17. ACE Study Facts • Adults with ACE score >4 are 460% more likely to have lifetime history of depression. • Adults with ACE score >5 are 16 times more likely to have lifetime history of alcoholism. • Male child with ACE score of 6 has 4,600% increase in likelihood of later becoming IV drug user.

18. Impact of Exposure to Trauma Can cause impairments in many areas of development & functioning, including: • Attachment – Difficulty relating to & empathizing with others; believe the world to be uncertain & unpredictable • Biology – problems with sensation & movement, including hypersensitivity to physical contact & insensitivity to pain; physical symptoms & increased medical problems

19. Impact of Trauma,cont. • Mood Regulation – difficulty identifying & controlling emotions & internal states • Behavioral Control - poor impulse control, self-destructive behavior, aggression, risk taking behavior • Dissociation – feeling detached, as if observing something happening to them that is not real

20. Impact of Trauma, cont. • Cognition – difficult focusing & completing tasks or anticipating future events; learning difficulties & problems with language development • Self-concept – feeling shame/guilt; low self-esteem, disturbed body image • Loss & Betrayal - loss of part(s) of their life; distrust of others • Powerlessness – perceive self as victim; have no say in what happens to them; unable to control their lives, etc.

21. Trauma and the Brain • Has serious consequences for normal development of children’s brains, brain chemistry & nervous system. • Trauma-induced alterations in biological stress symptoms can adversely effect brain development, cognitive & academic skills, & language development. • Result in increased levels of stress hormones (impacts response to future stress)

22. Trauma and the Brain, cont. • Affects “cross-talk” between brain’s hemispheres, including parts that: • regulate emotions • manage fears, anxieties & aggression • sustain attention for learning & problem solving • control impulses & manage physical responses to danger • allow realistic appraisal of danger & safety • promote consideration of consequences of behavior • allow ability to govern behavior & meet longer term goals

23. The Influence of Culture • People of different cultural, national, linguistic, spiritual & ethnic backgrounds may define & describe “trauma” differently • Assessment of trauma history should always take into account cultural background & modes of communication of assessor and family • Strong cultural identify & community/family connections can contribute to strength & resilience or can increase risk for & experience of trauma.

24. The Influence of Development • Child traumatic stress reactions vary by developmental stage. • Children with traumatic experiences may spend much energy responding to, coping with, & coming to terms with the experience – results in delays in mastering age-appropriate developmental tasks – delayed development • The longer traumatic stress goes untreated, the farther children tend to stray from appropriate developmental pathways.

25. Variability in Responses to Traumatic Events • The impact of a potentially traumatic event depend on • Individual’s age & developmental level • Individual’s perception of the danger faced • Whether the individual was victim or perpetrator • Individual’s relationship to victim or perpetrator • Individual’s past experience with trauma • Adversities the individual faces following the trauma • Presence/availability of others who can offer help/support/protection

26. TRIGGERS For trauma survivors, it is different…

27. T Triggers • Seeing, feeling, hearing, smelling something that reminds us of past trauma • Activates the alarm system… • The response is as if there is current danger. • Thinking brain automatically shuts off in the face of triggers. • Past and present danger become confused.

28. Our experience. A trauma survivor’s experience.

29. We all have buttons that can be pushed…

30. Your response is key- Greater chance for a Greater chance for a

31. Protective Factors • Parental/caregiver resilience • Social connections • Knowledge of parenting and child development • Concrete support in times of need • Nurturing and attachment/social and emotional competence of children

32. “It’s about the right to have a present and a future that are not completely dominated and dictated by the past.” Karen Saakvitne

33. TRAUMA INFORMED PRACTICE

34. TRAUMA INFORMED PRACTICE

35. TRAUMA INFORMED PRACTICE (Fallot & Harris, 2002; Cook et al., 2002, Ford, 2003, Cusack et al., Jennings, 1998, Prescott, 2000)

36. Trauma Informed Systems UNIVERSAL PRECAUTIONS Presume that every person in a treatment setting has been exposed to abuse, violence, neglect, or other traumatic event(s). “What has happened to you?”

37. Though no one can go back and make a brand new start, anyone can start from now and make a brand new ending. Carl Bard

38. Trauma is when people live with more fear than hope.

39. Trauma Recovery is when people live with more hope than fear…

40. What matters most… How people cope with trauma determined by: • How they experience what they are exposed to • Who they were exposed to in their traumatic past • What they are exposed to in the present environment

41. Trauma-Informed Care Trauma-Informed Care provides a new paradigm under which the basic premise for organizing services is transformed from “What’s wrong with you?” “What happened to you?” To

42. SUCCESS What happened to you?

43. Consider… John is a 16 year old boy who, with his younger brother, was placed in DHHR custody at age 5 as a result of parental abuse/neglect. He has been in multiple placements, including numerous foster homes, residential care in all levels, psychiatric inpatient care on multiple occasions. He has been been kicked out of all levels of care for disruptive behavior. He was diagnosed with ADHD, conduct disorder, bipolar disorder, and substance abuse. He was placed in detention for physical aggression/ assault. He has been in outpatient care several times, and is now court ordered to outpatient care again. His intake assessment was being done by his previous outpatient therapist. He got angry during the intake and stormed out of the office and agency.

44. What went wrong?

45. Trauma-Informed Systems When an agency takes the step to become trauma-informed, every part of its organization, management, & service delivery system is assessed & potentially modified to include a basic understanding of how trauma impacts the life of individuals seeking services.

46. Trauma-Informed Systems Trauma-informed organizations, programs, & services are based on an understanding of the vulnerabilities or triggers of trauma survivors that traditional service delivery approaches may exacerbate, so that these services & programs can be more supportive and avoid retraumatization.

47. TRAUMA-INFORMED CARE

48. Trauma-Informed and Trauma-Specific Services • The provision of “trauma-informed care” is a seminal concept in emerging efforts to address trauma in the lives of children, youth and adults. • In a trauma-informed system, trauma is viewed as “a defining and organizing experience that forms the core of an individual’s identity.” Source: Harris, M. and Fallot, R.D. (Eds), 2001

49. Trauma-Informed Paradigm • Understanding of Trauma • Understanding of the Consumer/Survivor • Understanding of Services • Understanding of the Service Relationship

50. Understanding of Trauma • Traumatic events are not rare; experiences of life disruption are pervasive and common • The impact of trauma is seen in multiple, apparently unrelated life domains • Repeated trauma is viewed as a core life event around which subsequent development organizes • Trauma begins a complex pattern of actions and reactions which have a continuing impact over the course of one’s life