Trauma Informed Care

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Creating Violence Free and Coercion Free Service
Environments for the Reduction of Seclusion and
Restraint

• Trauma Informed Care

An Overview of Fundamental Concepts A Primary
Prevention Tool Created by Huckshorn, Stromberg,
LeBel, 2004
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• What can we learn from the brave women who have
  shared their stories?
• How can we make our environments as sensitive as
  possible so we do no harm?
• How can we promote healing and recovery?

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Trauma Informed Care

• Defining Trauma Trauma Informed Care
• Prevalence in Persons across mental health,
  substance abuse, MRDD, Juvenile Justice Prison
  Populations
• Trauma Informed Trauma Insensitive Systems
• Trauma Assessment Clinical Implications

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What is Trauma?

• Definition (NASMHPD, 2004)
• The experience of violence and victimization
  including sexual abuse, physical abuse, severe
  neglect, loss, domestic violence and/or the
  witnessing of violence, terrorism or disasters.
• DSM IV-TR (APA, 2000)
• Persons response involves intense fear, horror,
  and helplessness
• Extreme stress that overwhelms the persons
  capacity to cope

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Types of Trauma Resulting in Serious Problems

• Are usually not a single blow event e.g. rape,
  natural disaster
• Are interpersonal in nature intentional,
  prolonged, repeated, severe
• Sexual Abuse, Physical Abuse, Severe neglect,
  Emotional Abuse
• Witnessing violence, repeated abandonment, sudden
  and traumatic Loss
• Occur in childhood and adolescence and may extend
  over an individuals life span
• (Terr, 1991 Giller, 1999, Felitti, 1998)

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Definition of TraumaInformed Care

• Treatment that incorporates
• An appreciation for the high prevalence of
  traumatic experiences in persons who receive
  services.
• A thorough understanding of the profound
  neurological, biological, psychological and
  social effects of trauma and violence on the
  individual and
• Care that addresses these effects, is
  collaborative, supportive and skill-based
• (Jennings, 2004)

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Prevalence of Trauma

• How significant a problem is trauma?
• What does the prevalence data for adults and
  adolescents in the mental health, substance
  abuse, MRDD, juvenile justice and prison systems
  tell us?

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Prevalence of TraumaMental Health Population
Adults

• 90 of public mental health clients in have been
  exposed to trauma
• (Muesar et al., in press Muesar et al.,
  1998)
• 51-98 of public mental health clients in have
  been exposed to trauma
• (Goodman et al., 1997, Muesar et al, 1998)
• Most have multiple experiences of trauma
• (Muesar et al, in press Muesar et al, 1998)
• Current rates of PTSD in people with SMI range
  from 29-43 (CMHS/HRANE, 1995 Jennings Ralph,
  1997)

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Prevalence of TraumaMental Health Population
Adults

• Study in South Carolina CMHC found 91 of clients
  had histories of trauma
• (Cusack, Frueh Brady, 2004)
• 97 of homeless women with SMI have experienced
  severe physical sexual abuse 87 experience
  this abuse both in childhood and adulthood
  (Goodman et al., 1997)
• Majority of adults diagnosed BPD (81) or DID
  (90) were sexually or physically abused as
  children (Herman et al, 1989 Ross et. al,
  1990)

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Prevalence of TraumaMental Health Population -
Children Adolescents

• Canadian study of 187 adolescents reported 42
  had PTSD (Saxe, 2004)
• American study of 100 adolescent inpatients 93
  had trauma histories and 32 had PTSD (Lipschitz
  et al, 1999)
• Medical record point in time review of 154
  children/adolescents 84 documented trauma
  histories (Massachusetts DMH, 2001)

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Prevalence of TraumaSubstance Abuse Population

• Up to two-thirds of men and women in SA treatment
  report childhood abuse neglect (SAMSHA CSAT,
  2000)
• Study of male veterans in SA inpatient unit
• 77 exposed to severe childhood trauma
• 58 history of lifetime PTSD (Triffleman et al,
  1995)
• 50 of women in SA treatment have history of rape
  or incest
• (Governor's Commission on Sexual and Domestic
  Violence, Commonwealth of MA, 2006)

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Incarcerated Women with Mental Health, Substance
Abuse and Trauma Histories

• Correctional Institute for Women, Massachusetts
• 90 receiving mental health services or substance
  abuse services have trauma histories
• (Dedicated External Female Offender Review,
  Governors Task Force, Commonwealth of Ma., 2005)
• Correctional Institute for Women, Rhode Island
• 40 - Childhood sexual abuse
• 55 - Childhood physical abuse
• 53 - Adult rape
• 63 - Adult physical assault
• 34 - Lifetime PTSD
• (Zlotnick, 1997 Zlotnick, Najavits et
  al, 2003)

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Prevalence of Trauma Children and Adolescents -
Juvenile Justice Settings

• Being abused or neglected as a child increases
  the likelihood of arrest as juvenile by 59
• (Widom, CS, 1995)
• Rates are up to 8 times higher than community
  samples of same-age peers (Saigh et al,
  1999 Saltzman et al, 2001)
• PTSD prevalence data varies widely 3 - 50 in
  JJ settings. (Arroyo, 2001, Garland et al,
  2001, Teplin et al., 2002)
• 70 - 92 of incarcerated girls reported sexual,
  physical, or severe emotional abuse in childhood
  (DOC, 1998 Chesney Sheldon, 1991)

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Prevalence of TraumaCorrectional Settings

• Some researchers describe a pathway in which
  exposure to violence and pervasive feelings of
  not being safe develop into a state of chronic
  threat requiring the youth/adult to use physical
  aggression in order to manage
• (Schwab-Stone et al, 1995)

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Prevalence of TraumaMR/DD Population

• Risk of abuse increases by 78 due to exposure to
  the disabilities service system alone
  (Sobsey Doe, 1991)
• Increased vulnerability to abuse in institutional
  settings (White, Holland, Marsland Oakes,
  2003)
• Sexual abuse incidents are 4 times as common in
  institutional settings as in community (Blatt
  Brown, 1986)
• Citations from Charlton et al (2004)

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Prevalence of TraumaMR/DD Population

• Widely believed to be prevalent and
  under-reported due to
• Difficulty communicating the abuse has occurred
• Difficulty being believed
• (Charlton, Kliethermes, Tallant,
  Taverne, Tishelman, 2004 Beail Warden, 1995)
• Estimates vary widely 8 to 100
• (Beail Warden, 1995
  Ryan, 2000 Sobsey, 1994)
• People with developmental disabilities are
  exposed to trauma and abuse more frequently than
  other people
• (Ryan, 2005 Sobsey, 1994 Blatt,
  1970)

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What does the prevalence data tell us?

• 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
• Growing body of research on the relationship
  between victimization and later offending

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What does the prevalence data tell us?

• Children and adults in MRDD settings are at
  particular risk
• Many people with trauma histories have
  overlapping problems with mental health,
  substance abuse, and are victims or perpetrators
  of crime
• Victims of trauma are found across all systems of
  care

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Therefore

• We need to presume the clients we serve have a
  history of traumatic stress and exercise
  universal precautions
• (Hodas, 2004)

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Other Trauma Correlates The Relationship of
Childhood Trauma to Adult Health

• Adverse Childhood Events (ACES) have serious
  health consequences
• Adoption of health risk behaviors as coping
  mechanisms
• eating disorders, smoking, substance abuse, self
  harm, sexual promiscuity
• Severe medical conditions heart disease,
  pulmonary disease, liver disease, STDs, GYN
  cancer
• Early Death (Felitti et al, 1998)

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Core Issue Avoidance of Shame and Humiliation

• Gilligan, in his prison research identified
  shame/humiliation as core element in violence
• Garbarino addresses the impact of trauma on boys
  predilection to antisocial behavior by
  regaining control through aggression
• Denial of abuse and emotions
• Explosion with little provocation
  hypersensitivity when not feeling respected
• (Gilligan Lee, 2004 Garbarino, Lost
  Boys Why Our Sons Turn Violent and How We Can
  Save Them, 1999)

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Problem ResponsesJ. Garbarinos lost boys

• Since issues of shame are pervasive - allow
  child to save face
• Juvenile vigilantism as a survival strategy
• Gang affiliation offers a new/better family
• Lack of future orientation, sense of
  meaninglessness tendency to take
  risks (Garbarino, 1999 Hodas, 2004)

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• Trauma Informed Care
• Systems

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Trauma Informed Care SystemsKey Principles

• Are based on current literature
• Are informed by research and evidence of
  effective practice
• Recognize that coercive interventions cause
  traumatization and re-traumatization and are to
  be avoided

(Fallot Harris, 2002 Ford, 2003 Najavits,
2003)
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Trauma Informed vs. Non Trauma Informed Care

• What do trauma informed care (TIC) systems look
  like?
• How are they different from care systems that are
  not informed by trauma (NTIC)?

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Trauma Informed Non Trauma Informed

• Lack of education on trauma prevalence
  universal precautions
• Over-diagnosis of schizophrenia bipolar do,
  conduct do singular SA disorders
• Person seen without family/social history
• Cursory or no Trauma Assessment
• Tradition of Toughness valued as best care
  approach

• Recognition of high prevalence of trauma
• Recognition of primary and co-occurring trauma
  diagnoses
• Life context/exposure is appreciated
• Assess for Traumatic Histories Symptoms
• Recognition of culture and practices that are
  re-traumatizing

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Trauma Informed Non Trauma Informed

• Power/Control minimized - constant attention to
  culture
• Counselors, Staff
• Caregivers/Supporters Collaboration
• Address training needs of staff to improve
  knowledge sensitivity

• Keys, Security Uniforms, staff demeanor, tone of
  voice
• Techs, Guards
• Rule Enforcers Compliance
• Patient-blaming as fallback position without
  training

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Trauma Informed Non Trauma Informed

• Understand function of behavior (rage,
  repetition-compulsion, self-injury)
• Objective, neutral language
• Includes survivors perspective
• Psycho-education and alternative skill
  development
• Transparent systems open to outside parties

• Behavior seen as intentionally provocative
  volitional
• Labeling language manipulative, needy, gamey,
  attention-seeking
• Lack of self-directed care
• Over-reliance on medication without skills focus
• Closed system advocates discouraged

(Fallot Harris, 2002 Cook et al., 2002 Ford,
2003 Cusack et al., 2004 Jennings, 1998
Prescott, 2000)
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Trauma Informed Non Trauma Informed
Language

• Asking people how they prefer to be addressed
• Quietly making rounds and informing people of
  schedule
• Lets talk and find you something to do
• May I help you?

• Calling people by name without permission or last
  name w/out title
• Yelling lunch or medications
• If I have to tell you one more time .
• Step away from the desk

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Trauma Informed Non Trauma InformedWhat
would be observed in a setting?

• Larges barrier around nursing station Us/Them
• Checks to simply locate focus on task, not
  person
• Coming in and leaving without acknowledgement

• Modified nursing station without barrier
  welcoming and open
• Checks to check-in with the person eye contact
• Saying hello and goodbye at beginning and end of
  shift

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• Trauma Assessment

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Trauma Assessment Key Principles

• Purpose
• Used to identify past or current trauma,
  violence, abuse
• Assess related sequelae
• Provides context for current symptoms and guides
  clinical approaches and recovery progress

(Cook et al., 2002 Fallot Harris, 2002 Maine
BDS, 2000)
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Trauma Assessment Minimal Components

• Type
• Sexual, physical, emotional, neglect, witnessed
  domestic violence, exposure to disaster, combat
  exposure, other
• - Single, one-time event, multiple events or
  chronic long term event?
• Age
• When the abuse occurred is important in terms of
  developmental impact
• Who
• Was perpetrator a stranger? Family member?
  

(Carmen et al, 1996)
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Trauma Assessment Key Principles

• Early and thoughtful diagnostic evaluation with
  focused consideration of trauma in people with
  complicated, treatment-resistant illness in
  mental health, substance abuse, domestic
  violence, JJ, corrections and MRDD settings.
• Tailor the assessment to the appropriate
  developmental level of the individual
• Noting that people who are psychotic and
  delusional can respond reliably to trauma
  assessments if questions are asked appropriately
  (Rosenberg et al,
  2001)
• Noting that people with trauma histories/disorders
  may not be able to become sober unless trauma
  symptoms are addressed as part of stabilization
  plan (Najavitz, 1997)

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Trauma Assessment Key Principles

• Advance directives, safety plans and
  de-escalation preferences are communicated and
  used in day-to-day care
• Individuals should not have to disclose trauma
  histories to receive trauma-informed care
  
• Since we may not always know, presume that every
  person in a treatment setting has been exposed to
  abuse, violence, neglect or other traumatic
  experiences (Hodas, 2004)

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Trauma Assessment Key Principles

• Focusing on what happened to you in place of what
  is wrong with you (Bloom, 2002)
• Interview is conducted upon admission or shortly
  after
• Importance of therapeutic engagement during
  interview cannot be over emphasized

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Trauma Assessment Key Principles

• Asking questions about current abuse
• Addressing the current risk and developing a
  safety plan for discharge
• Results and positive responses must be
  addressed in care planning or assessment has no
  value.
• For children, assessment through play and
  behavioral observation
• What happened when disclosed? More loss or was
  there appropriate protection?

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Assessment of Symptoms Behavior

• Dissociation
• Flashbacks
• Nightmares
• Hyper-vigilance
• Terror
• Anxiety
• Pejorative auditory hallucinations

• Numbness,
• Depression
• Substance abuse
• Self-injury
• Eating problems
• Poor judgment and continued cycle of
  victimization

• (DSM IV-TR, 2000)

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Immediate Concerns that Require Intervention

• Continued trauma experiences including partner
  violence
• Lack of safety in hospital, community/MRDD
  residence, prison, home, community or other
  treatment setting
• Need for collateral involvement with other state
  agencies child welfare, elderly services,
  domestic violence, mental health etc.

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Trauma Informed Treatment Safety and Stabilization

• Requires integrated treatment for MH and SA
  w/premise trauma is central to development of
  both disorders (NTAC, 2004)
• Address impact of trauma on health and need for
  health prevention
• In general, focus on skill development rather
  than exploration of traumatic events,
• Cognitive-behavioral approaches demonstrate
  effectiveness cognitive restructuring,
  skills-training, psychoeducation
• (Harvey et al, 2003 Najavits, 2003)

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• Consider population specific care
• Intervening in the community environment for
  children, elderly, people with MRDD
• (Saxe et al, 2004)
• Using drawing, sculpting, mastery exercises for
  children
• Using medication judiciously for targeted
  symptoms such as depression, hyper arousal and
  over-reactivity

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Trauma Stages of Recovery Stage 1 Safety
Stabilization Herman, 1992

• Skill Development
• Trigger identification
• Coping skills as alternatives to self-destructive
  behavior
• Emotional Regulation
• Self-Care
• Self-Soothing
• Assertiveness Training
• Judgment self-protection

(Linehan M, 1993 Najavitz, 1997)
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Trauma Stages of Recovery Stage 1 Safety
Stabilization

• Psycho-education
• Impact of trauma
• Body with attention to physical care
• Sense of self (damaged goods)
• Relationships
• Addressing substance abuse
• Recognition of danger
• Making choices
• Healthy relationships vs. unhealthy relationships
• Setting goals
• Setting up supports
• (Linehan, 1993 Najavitz, 1997)

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In Summary..

• Appreciate high prevalence rates
• Understand the characteristics of Trauma-Informed
  Care and how this differs from care that is not
  informed by trauma
• Assess histories and symptoms of trauma and link
  to treatment plans/crisis plans
• Provide psycho-education and support skill
  development
• Training for all staff on Trauma-informed Care

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We must meticulously remember.

• Any intervention that recreates aspects of
  previous traumatic experiences or that uses power
  to punish is harmful to the individual involved
• (NASMHPD, 1998)