Trauma-Informed CareEmpowering. Engaging. Effective.

Joann StephensStable Life, Inc.

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?

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)

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)

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

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

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

Complex Trauma / Complex PTSD / Developmental Trauma Disorder

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

Symptoms of Complex TraumaRe-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

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

“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.”

Vicarious or Secondary Trauma

The experience of learning about another person’s trauma and experiencing trauma-related distress as a result of this exposure

Adverse Childhood Experience (ACE) Study

http://www.acestudy.org/

http://www.cdc.gov/nccdphp/ACE/

‘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

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%

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

Impact of Trauma Over the Life Span

Effects of childhood adverse experiences: neurological biological psychological social

Beginning to Understand‘Disrupted Neurodevelopment’

• Fight: resist• Flight: run

away• Freeze: stay

still

The Stress Response and the Brain

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

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)

Immediate Aftermath of Abuse

What you may see:

• Nothing• Laughter• Shut down / numb• Others?

What you may not see:

• Confusion

• Guilt / Shame

• Fear

• Others?

Institute for Health and Recovery

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

Ee

R

E - A Large Event

e - A Small Event

R - A Large Reaction

Past Present

Complex Trauma – Impact on Development

Impact on WorldviewImpact on WorldviewTypical Development vs. Developmental TraumaTypical Development vs. Developmental Trauma

• Nurturing & stable Nurturing & stable attachments with adultsattachments with adults

• Belief in a predictable & Belief in a predictable & benevolent world/ benevolent world/ generally good things will generally good things will happen to mehappen to me

• Feeling of positive self-Feeling of positive self-worth /others will see my worth /others will see my strengthsstrengths

• Optimism about the futureOptimism about the future• Feeling that I can have a Feeling that I can have a

positive impact on the positive impact on the worldworld

• Basic mistrust of Basic mistrust of adults/inability to depend adults/inability to depend on otherson others

• Belief that the world is an Belief that the world is an unsafe place/bad things unsafe place/bad things will happen & they are will happen & they are usually my faultusually my fault

• Assumption that others Assumption that others will not like mewill not like me

• Fear & pessimism about Fear & pessimism about futurefuture

• Feelings of hopelessness Feelings of hopelessness & lack of control& lack of control

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

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

Shame and HumiliationThe 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)

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

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

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

Guiding Values of Trauma-Informed Care

Healing Happens in Relationship

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

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

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

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)

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

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.

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)

Contact Information

Elizabeth Hudson, LCSWTrauma-Informed Care ConsultantWI Dept. of Human ServicesDivision of Mental Health and Substance Abuse Services

608-266-2771Elizabeth.Hudson@wisconsin.gov

Employed by University of Wisconsin -School of Medicine and Public Health