Trauma-Informed Care

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

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Trauma-Informed Care

• What it is a philosophical shift
• What it is not an intervention to address PTSD
• What happened to you?
• vs.
• Whats wrong with you?

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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)

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Psychological Trauma - What is it?

• Trauma refers to extreme stress (e.g., threat to
  life, bodily integrity or sanity) that overwhelms
  a persons ability to cope.
• The individuals 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 ones place in the world.
• (Giller, 1999 Herman, 1992)

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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

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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

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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

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Complex Trauma / Complex PTSD / Developmental
Trauma Disorder

• Result of traumatic experiences that are
  interpersonal, intentional, prolonged and
  repeated

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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

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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

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• I had been coerced into treatment by people
  who said they were trying to helpThese 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.

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Vicarious or Secondary Trauma

• The experience of learning about another
  persons trauma and experiencing trauma-related
  distress as a result of this exposure

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Adverse Childhood Experience (ACE) Study

• http//www.acestudy.org/
• http//www.cdc.gov/nccdphp/ACE/

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ACE

• 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

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ACE Score Trauma Dose
Number of individual types of adverse childhood
experiences were summed
ACE score Prevalence 0 32
1 26 2 16 3 10 4 or more 16
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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

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Impact of Trauma Over the Life Span

• Effects of childhood
• adverse experiences
• neurological
• biological
• psychological
• social

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Beginning to UnderstandDisrupted
Neurodevelopment

• Fight resist
• Flight run away
• Freeze stay still

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The Stress Response and the Brain

• If there is danger the thinking brain shuts
  down, allowing the doing brain to act.

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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)

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Immediate Aftermath of Abuse

• What you may see
• Nothing
• Laughter
• Shut down / numb
• Others?

• What you may not see
• Confusion
• Guilt / Shame
• Fear
• Others?

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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
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R
E
e
Past
Present
E - A Large Event e - A Small Event R -
A Large Reaction
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(No Transcript)
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Complex Trauma Impact on Development
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Impact on WorldviewTypical Development vs.
Developmental Trauma

• 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

• 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

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Understanding Behaviors Explanation vs. Excuse

• Internal defense
• Withdrawal
• Substance use
• Eating Disorders
• Violence to self
• Dissociation

• External defense
• Anger / defiance
• Violence towards others
• Truancy
• Criminal acts

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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 persons negative beliefs
• Help vent frustration, anger and anxiety
• Give a sense of mastery over the old traumas

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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)

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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

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Our labels dont 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

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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

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Guiding Values of Trauma-Informed CareHealing
Happens in Relationship
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What does it look like?

• Traditional
• Key Question Whats 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

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Comparison of Systems (contd)

• 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

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Practice Based on TIC ValuesValue Pursue the
persons strengths, choice and autonomy

• 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

• TRADITIONAL
• 1. Everyone goes to bed at 1030 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

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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 whats 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
  doesnt do something that seems to be common
  sense, be curious
• (Bloom, 2009)

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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

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Sample of Models, Guides and Resources

• The Anna Institute. http//www.annafoundation.or
  g/
• 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.

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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)

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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_at_wisconsin.gov
• Employed by University of Wisconsin -
• School of Medicine and Public Health