Trauma-Informed Care and Basics of Trauma

1. Trauma-Informed Care and Basics of Trauma Tobi Russell MS LLP, MA LLPC, NCC, CAADC, CCS-M, BCETS Director, Rochester Hills Counseling

2. Objectives • Understand the difference between trauma-informed care and trauma-specific services • Be able to identify various types of trauma • Learn how trauma can impact both our mental health and substance abuse clients • Receive an introduction to crisis theory

3. Objectives • Recognize what trauma may look like for adults and what trauma may look like for children • Be able to identify trauma interventions that can be used with adults and interventions that can be used with children/adolescents • Understand ways that we can create a trauma-informed culture

4. What is Trauma-Informed Care? • Trauma-informed programs and services represent the “new generation” of human services organizations and programs who serve people with histories of violence and trauma.

5. What is Trauma-Informed Care? • Trauma survivors in these programs and services are likely to have histories of physical and sexual abuse and other types of trauma-inducing experiences • These experiences lead to mental health and other types of co-occurring issues such as health problems, substance abuse problems, eating disorders, and contact with the criminal justice system.

6. What is Trauma-Informed Care? • Trauma-informed services are not: • Designed to treat symptoms related to abuse or other trauma • Trauma-informed services are: • Informed about, and sensitive to, trauma-related issues present in survivors • Where all components of an agency are geared towards the basic understanding of the role trauma in the lives of clients

7. What is Trauma-Informed Care? • Integrate philosophies of care that guide all clinical interventions • Based on current literature • Inclusive of the survivor's perspective • Informed by research and evidence of effective practice • Recognize that coercive interventions cause traumatization and re-traumatization is to be avoided (Fallot & Harris, 2002; Ford, 2003; Najavits, 2003)

8. What are Trauma-Specific Services? • Trauma-specific services are: • Designed to treat the actual consequences of trauma • Focused on the need for respect, information, connection, and hope for clients • Aware of the adaptive function of symptoms • Designed around the need to work collaboratively in a person-directed and empowering way

9. What is Trauma? • An injury (as a wound) to living tissue caused by an extrinsic agent • Adisordered psychic or behavioral state resulting from severe mental or emotional stress or physical injury • An emotional upset Merriam-Webster’s Dictionary

10. What is Trauma? • The issue of whether an event has to satisfy current diagnostic definitions of trauma in order to be “traumatic” to an individual is an ongoing source of debate • However, many believe that an event is traumatic if it is extremely upsetting and at least temporarily overwhelms the individual’s internal resources (Briere & Scott, 2006)

11. PTSD Diagnostic Criteria The development of characteristic symptoms, following exposure to a traumatic stressor involving direct personal experience or witnessing another persons’ experience of: • Actual or threatened death • Actual or threatened serious injury • Threat to physical integrity • Characterized by: • Re-experiencing the event • Intrusive thoughts, nightmares, or flashbacks that recollect traumatic images and memories • Avoidance and emotional numbing • Flattening of affect, detachment from others, loss of interest, lack of motivation, and constant avoidance of any activity, place, person, or event associated with the traumatic experience • Symptoms of increased arousal • D1. Sleep disturbances • D2. Outbursts of anger • D3. Difficulty concentrating • D4. Hypervigilance

12. What is Trauma? • Until the last decade or so, trauma exposure was thought to be rare (combat violence, disaster trauma) (Kessler et al., 1995) • Studies done in the last decade indicate that trauma exposure is common • (Ibid) • 56% of an adult sample reported at least one event (Ibid)

13. What is Trauma? Physical/Sexual/Emotional Abuse House fire Car Crash Natural Disaster Mass Violence or accidents Domestic Violence War Large-scale transportation accidents Emergency worker exposure to trauma

14. What is Trauma? Death of a loved one Loss of a job Time spent in jail/prison Separation/Divorce Loss of home Children going to foster care placement Being diagnosed with a health condition

15. Statistics • A report of child abuse is made every 10 seconds in the United States. (Childhelp, 2013) • Children who experience child abuse and neglect are 59% more likely to be arrested as a juvenile, 28% more likely to be arrested as an adult, and 30% more likely to commit violent crime. (Child Welfare Information Gateway, 2006)

16. Statistics • Trauma histories are pervasive among youth in America(Marcenich, 2009) • Children with disabilities are more likely to experience neglect than children without disabilities.(Child Welfare Information Gateway, 2006) • Nearly 80% of female offenders with a mental illness report having been physically and/or sexually abused.(Marcenich, 2009)

17. Statistics • More than 1 in 3 women (35.6%) and more than 1 in 4 men (28.5%) in the United States have experienced rape, physical violence, and/or stalking by an intimate partner. (CDC, 2013) • 75% of women and men in treatment for substance abuse report trauma histories. (SAMHSA/CSAT, 2000)

18. Statistics “Individuals with a trauma history rarely experience only a single traumatic event, but rather are likely to have experienced several episodes of traumatic exposure.” Cloitre et al., 2009

19. Statistics • Up to two-thirds of men and women in SA treatment report childhood abuse & neglect (CSAT/SAMHSA, 2000) • 50% of women in SA treatment have history of rape or incest (Governor's Commission on Sexual and Domestic Violence, Commonwealth of Massachusetts, 2006)

20. What does this mean? • The majority of adults and children in psychiatric treatment settings have trauma histories • A sizable percentage of people with substance abuse disorders have traumatic stress symptoms that interfere with achieving or maintaining sobriety • A sizable percentage of adults and children in the prison or juvenile justice system have trauma histories

21. Universal Precautions as a Trauma-Informed Concept “Many providers may assume that trauma experiences are additional problems for the person, rather than the central problem…” (Hodas, 2004)

22. Universal Precautions as a Trauma-Informed Concept Presume that every person in a treatment setting has been exposed to abuse, violence, neglect, or other traumatic experiences.

23. Study Findings

24. Adverse Childhood Experiences The ACE study identifies adverse childhood experiences as growing up (prior to 18 years of age) in a household with: recurrent physical abuse; recurrent emotional and/or sexual abuse; an alcohol abuser; an incarcerated household member; someone who is chronically depressed, suicidal, institutionalized, or mentally ill; mother being treated violently; one or no parents; emotional or physical neglect. (Felitti et al., 1998)

25. Adverse Childhood Experiences(www.ACEstudy.org) • Are neurological, biological, psychological and social in nature. They include: • Changes in brain neurobiology • Social, emotional & cognitive impairment • Adoption of health risk behaviors as coping mechanisms (eating disorders, smoking, substance abuse, self harm, sexual promiscuity, violence) • Severe and persistent behavioral health, health and social problems, early death (Felitti et al, 1998; Herman, 1992)

26. Lateral Ventricles Measures in an 11 Year Old Maltreated Male with Chronic PTSD, Compared with a Healthy, Non-Maltreated Matched Control (De Bellis et al, 1999

28. Introduction to Crisis Theory “Crisis is not a pathological state; it may occur to anyone at any stage in his or her life span.” (Golan, 1978).

29. Crisis Theory Danger Opportunity • Debilitation • Deterioration • Lower functioning • Growth • Higher functioning • Transcendence

30. Crisis Theory EVENTS Sudden, short-lived changes that happen to a system at a time and place. They have an immediate impact like and accident, an earthquake, etc. CONDITIONS Conditions exist over a period of time and represent a state of being. Conditions describe interpersonal and physical environments of the organism.

31. Activity Sue is a 32 year old single mother of two children (ages 13 and 10). Two months ago her ex-husband left the state and stopped paying child support. Sue is a computer clerk at a local bank. On some days she sits in front of her terminal for 8 hours. Sue is crowded with seven other women into a small basement room which has poor ventilation, fluorescent lighting, no windows, and a faulty thermostat.

32. Activity Answer Sue is a 32 year old single mother of two children (ages 13 and 10). Two months ago her ex-husband left the state and stopped paying child support. Sue is a computer clerk at a local bank. On some days she sits in front of her terminal for 8 hours. Sue is crowded with seven other women into a small basement room which has poor ventilation, fluorescent lighting, no windows, and a faulty thermostat.

33. Crisis Theory • Crises can happen to individuals, families, small groups • Stress is a “fuzzy” concept ; easier to think of stressors • Some stressors happen suddenly (events) • Some stressors exit over a period of time (conditions) • Events can be easier to recognize than conditions; events can sometimes evolve into conditions

34. Crisis Theory Stressors occur on a continuum from eustress to distress….on the distress side, Microstressor Traumatic Normative Hazardous

35. Crisis Theory The diagram below shows the relationship between stress and arousal as determined by a factor analytic technique (Mackay et al 1978)

36. What Trauma May Look Like for Adults • Shock, denial, or disbelief • Anger, irritability, mood swings • Guilt, shame, self-blame • Feeling sad or hopeless • Confusion, difficulty concentrating • Anxiety and fear • Withdrawing from others • Feeling disconnected or numb

37. What Trauma May Look Like for Adults • Insomnia or nightmares • Being startled easily • Racing heartbeat • Aches and pains • Fatigue • Difficulty concentrating • Edginess and agitation • Muscle tension

38. What Trauma May Look Like for Adults • Having trouble functioning at home or work • Unable to form close, satisfying relationships • Experiencing terrifying memories, nightmares, or flashbacks • Avoiding more and more things that remind you of the trauma • Using alcohol or drugs to feel better

39. What Trauma May Look Like For Children/Adolescents The ability to form healthy relationships is highly dependent on learned social skills • Children’s social skill learning is directly related to the characteristics of their environments • Disordered environments=dysfunctional skills • Violence teaches withdrawal, anxiety, distrust, over-reaction and/or aggression as coping behaviors • Extreme behaviors are rooted in dysregulated emotional states (NF Commission, 2003; SG Report, 1999; Hodas, 2004; Saxe et al, 2003)

40. What Trauma May Look Like For Children/Adolescents • Appear guarded and anxious • Are difficult to re-direct, reject support • Are highly emotionally reactive • Have difficulty “settling” after outbursts • Hold onto grievances • Do not take responsibility for behavior • Make the same mistakes over and over (Hodas, 2004)

41. What Trauma May Look Like For Children/Adolescents • World is threatening and bewildering • World is punitive, judgmental, humiliating and blaming • Control is external, not internalized • People are unpredictable and untrustworthy • Defend themselves above all else • Believe that admitting mistakes is worse than telling truth • Using substances to feel better (Hodas, 2004)

42. Assessment • Purpose • Used to identify past history of trauma, violence, abuse, and related symptoms. • Assists with diagnostic reliability, clinical approaches and recovery progress. • Informs the treatment culture to minimize potential for re-traumatization. (Cook et al., 2002; Fallot & Harris, 2002; Maine BDS, 2000)

43. Assessment • Use of PTSD measures can add additional information. • Posttraumatic Diagnostic Scale for adults (Foa et al., 1997) • Child PTSD Symptom Scale (Foa et al., 2001) • Trauma Profile (Carnes, 1997) • Davidson Trauma Scale • Trauma Symptom Inventory • Trauma Symptom Checklist for Children

44. Assessment Identify Triggers • Not being listened to • Lack of privacy • Feeling lonely • Darkness • Being teased or picked on • Feeling pressured • People yelling • Arguments • Being isolated • Being touched • Loud noises • Not having control • Being stared at

45. Assessment Identify Early Warning Signs • Clenching teeth • Wringing hands • Bouncing legs • Shaking • Crying • Giggling • Heart Pounding • Eating more • Breathing hard • Shortness of breath • Clenching fists • Loud voice • Rocking • Pacing • Swearing • Restlessness

46. Assessment Identify Strategies • Time alone • Reading a book • Pacing • Coloring • Hugging a stuffed animal • Deep breathing • Talking to peers • Exercising • Writing in a journal • Listening to music • Ripping paper • Molding clay • Bubble bath, shower

47. Interventions for Adults • An overall approach that is respectful and positive, supportive and validating • Psychoeducation on trauma and trauma symptoms • Some form of stress reduction/affect regulation training • Cognitive interventions that address harmful or debilitating trauma-related beliefs, assumptions, and perceptions

48. Interventions for Adults • Opportunities to develop a coherent narrative about the traumatic event • Memory processing, usually involving guided self-exposure to trauma memories • Processing of relational issues in the context of a positive therapeutic relationship • Exploration activities that increase self-awareness and self-acceptance

49. Central Treatment Principles • Provide and ensure safety • Provide and ensure stability-life and emotional • Maintain a positive and consistent therapeutic relationship • Tailor the therapy to the client • Take gender issues into account

50. Key Messages for Trauma Recovery 1. It is not happening now. 2. You are safe. 3. You are not inherently dangerous/toxic. 4. You are good. 5. You have a future.