1. Trauma and Trauma-Informed Care

2. About UsTim Welsh LCSWMental Health CoordinatorWilliam WoodardPeer Support SpecialistPhoenix Health CenterHealth Care for the Homeless Site 3. What is Trauma Impact of Trauma Prevalence Data Core Principles of Trauma-Informed Care Practicing Trauma-Informed Care Challenges/ Effective Methods of Implementation Impact of Trauma Work / Self-Care for the WorkerOverview 4. The experience of violence and victimizationincluding sexual abuse, physical abuse, severeneglect, loss, domestic violence and/orwitnessing of violence, terrorism, anddisasters.(NASMPHD, 2006) 5. Trauma . . . Is sudden, unexpected, and perceivedas dangerous or life threatening Overwhelms individuals ability tomanage daily business as usual 6. Traumatic Experiences Sexual abuse and/or sexual assault Severe Neglect Physical abuse/violence War Accidents, injury, serious medical illness Deprivation caused by extreme poverty Gang and drug-related violence Imprisonment Oppression Witnessed violence and cruelty to others Emotional and psychological abuse Repeated abandonment or sudden loss 7. Trauma is Person-SpecificTwo people who view/experience the sameevent/trauma may not react in the samemanner.What is traumatic for one person may not betraumatic for another 8. The Impact of Trauma 9. The Impact of Trauma Body & Brain: Neurobiology- fight/flight/freeze response.Survivors often feel the biological responses offight/flight/freeze all the time and cant act on it, leaving themin constant state of hyperarousal, fear and anxiety Memory & Perception: Often fragmented and difficultyconcentrating Judgment: Insight, perspective, ability to see and weighconsequences, ability to set boundaries. Imagine the effectson ones judgment if their caregivers had also their abusers.They could have an inability to recognize red flags.(Saakvitne, et al., 2000) 10. The Impact of Trauma Beliefs: What it means to feel safe, trust, have self-esteem, feel connected, and to feel in control in ourlives. Frame of Reference: Identity (Who am I?); World view(What is the world really like?); Spirituality (What do Ibelieve?) Feelings: Ability to identify and manage feelings.Ability to connect to others(Saakvitne, et al., 2000) 11. Prevalence of TraumaSubstance Abuse Population- United States Up to 2/3s of men and women in substance abusetreatment report childhood abuse and neglect Study of male veterans in substance abuse inpatientunit found: 77% exposed to severe childhoodtrauma; 58% history of lifetime PTSD 50% of women in substance abuse treatment havehistory of rape or incest(Governors Commission on Sexual and Domestic Violence, Commonwealth of MA, 2006; SAMHSA CSAT, 2000;Triffleman et al., 1995) 12. ACE Adverse Child Experiences Studyhttp://www.acestudy.org Recurrent physical abuse Recurrent emotional abuse Contact sexual abuse An alcohol and/or drug abuse in the home An incarcerated household member Someone who is chronically depressed, mentallyill, institutionalized, or suicidal Mother is treated violently One or no parents Emotional or physical neglect (Anda & Felitti, 1998) 13. ACE Study Findings ACEs have a significant impact on later adult health andwell-being ACEs have a strong influence on the development ofhigh risk behaviors (i.e. smoking, illicit drug use, sexualbehavior) ACEs increase the risk of physical health issues (heartdisease, lung disease, HIV and STDs, obesity)(Anda & Felitti, 1998) 14. ACE Scores and Behavior ACE Score > 4 Twice as likely to smoke Seven times as likely to have alcohol abuse/dependence Twice as likely to have cancer or heart disease Four times as likely to have emphysema or COPD Twelve times as likely to have attempted suicide(Anda & Felitti, 1998) 15. ACE Scores and Behavior cont. Men with an ACE score of > 6 were 46 timesmore likely to use IV drugs People with ACE score of > 7Who did NOT smoke, drink to excess or weigh more thanhealthy weight range had a 360% higher risk of ischemicheart disease(Anda & Felitti, 1998) 16. History of Trauma Among Homeless AdultsChildhood:27% lived in foster care, group home or otherinstitutional setting.25% were physically or sexually abused.21% were homeless.Adulthood:23% are veterans.15.3% of jail inmates have been homeless atsome point and have high rates of othertraumatic experiences:-31% have been phsycially or sexuallyabused.-46% have been shot at (excludes militarycombat)-49% have been attacked with a knife orother sharp object.(Burt et al., 1999; National Coalition for the Homeless, 2007) 17. History of Trauma Among Homeless AdultsWomen: 97% of homeless women with SMI haveexperienced severe physical & sexual abuse-87% experience this abuse both in childhoodand adulthood. 92% of homeless mothers have experiencedsevere physical or sexual assaults over theirlifespan.Men: A 2010 study looked at the prevalence oftrauma for 239 homeless men and found:68% reported childhood physical abuse71% reported adulthood physical abuse56% reported childhood sexual abuse53% reported adulthood sexual abuse(Bassuk et al., 1996; Kim et al., 2010) 18. Histories of Trauma Among Youth Family conflict/violence is the primarycause of homelessness. 46% have been physically abused. Foster care involvement: One in five youth who arrived at shelters came directlyfrom foster care. Over 25% had been in foster care in the previous year.(U.S. Department of Health and Human Services, 1997) 19. Histories of Trauma Among LGBT Youth Comprises 20% to 40% of homeless youth. Coming out is often associated with beingkicked out of home or physically assaulted. Risky sexual behaviors are prevalent(increasing the risk of HIV). Seven times more likely to be a victim of violent crime.(National Gay and Lesbian Task Force Policy Institute and the National Coalition for the Homeless, 2006) 20. Trauma-Informed Care is Trauma-Informed Care is a strengths-based framework that is grounded in anunderstanding of and responsiveness tothe impact of trauma, that emphasizesphysical, psychological and emotionalsafety for both providers and survivors, andthat creates opportunities for survivors torebuild a sense of control andempowerment.(Hopper et. al., 2010) 21. Trauma-Informed Care is An understanding of what trauma is and how it effectspeoples outlook and behavior. A manner of interacting with clients with the assumptionthat they have experienced trauma. This ensures that allcommunication is less likely to trigger a negative responsein clients while at the same time conveying safety, care andrespect. Agency wide. From the front office staff, the socialworkers to the janitors. 22. We work to establish relationships with people who mayhave been humiliated, hurt or betrayed by those who aresupposed to be counted on for safety and protection.What does all this mean for our work? 23. Why Trauma-Informed? Misunderstood or ignored signs of trauma may: Interfere with help-seeking Limit engagement into services Lead to early drop out Inadvertently re-traumatize people we are trying to help Lead to failure to make appropriate referrals(Peterson, 2011) 24. The Core Principles of aTrauma-Informed Culture Safety: Ensuring physical and emotional safety; do no harm Trustworthiness: Maximizing trustworthiness, making tasksclear, maintaining appropriate boundaries Choice: Prioritizing consumer choice & control over recovery Collaboration: Maximizing collaboration & sharing of powerwith consumers Empowerment: Identifying what a person can do forthemselves; prioritizing skill-building that promotes recovery;helping consumer find inner strengths to heal(Adapted from Beyer, L.L., 2010) 25. Trauma-Informed CareWhat has happened to you?Instead ofWhat is wrong with you? 26. Using a Trauma LensAttitudes and behaviors arethe individuals best attempt to cope. 27. Trauma-Informed CareWe need to presume the clients we serve havea history of traumatic stress and exerciseuniversal precautions by creating systems ofcare that are trauma-informed. (Hodas, 2005) 28. Viewing Symptoms as Adaptations A TIC model frames survivors symptoms asadaptation, rather than as pathology Every symptom helped a survivor in the past andcontinues to help in the present in some way Emphasizes resilience in human response to stress Reduces shame Engenders hope for clients and providers alike 29. Viewing Symptoms as Adaptations Not trusting anyone Hypervigilence Not asking for help Fear of shelters Fear of crowds Not bathing (Shelters with open shower stalls) Not willing to use medical or dental services Not taking medications(Schilling, 2010) 30. Viewing Symptoms as Adaptations Aggression Not waiting for appointments; staying on the move Finding a protector Self-destructive behavior Self-harm Suicidality Exchanging sex for money or necessities Use of drugs and/or alcohol(Schilling, 2010) 31. Challenges in ImplementingTrauma Informed Care 32. Challenges in ImplementingTrauma Informed Care Differing Philosophies Lack of Time Ignorance Old Habits Die Hard Physical/space limitations 33. Ways of Ensuring EffectiveImplementation ofTrauma Informed CareClient input (!)Mystery ShoppersKeep your eyes and ears openAnalyze and learn from failures/system breakdownsTrain and Retrain 34. SafetyThe first stage of healing from trauma:Establish SAFETY(Herman, 1997) 35. Establishing Physical and Emotional Safety Speak in a calm, respectful voice Provide consumer with personal space Establish a safe place to talk and be alert to signs of discomfort or unease Emphasize consumer ability to stop discussion and model respect forconsumer choices Try to make space as calm and relaxing as possible, including removing anypotential triggers for trauma Validate feelings and honor honesty 36. Safety Use What is safe? question as a tool foridentifying action steps towards recovery. Engage consumer in discussion of rating safety ofdifferent options as well as determining specificways to increase level of safety. The goal of services is to return a sense ofautonomy and control through safer choice-making.(Najavits, 2002) 37. Creating a Safe Environment Minimize re-victimization Avoid such strategies as: Shaming Moral inventories in isolation Confrontation Intrusive monitoring Reduce triggering situations.(Schilling, 2010) 38. Triggering Procedures or Situations Lack of control/ Powerlessness Threat or use of physical force Interacting with authority figures Loud noises Lack of information Intrusive or personal questions Unfamiliar surroundings Reminders of the past Others?(Schilling, 2010) 39. Creating a Safe EnvironmentWhen an event is likely to be triggering Acknowledge Help the consumer to predict what will happen Give as much choice and control as possible Encourage use of self-regulation strategies during the event Make space for recovery after event Encourage/provide self-soothing during the event(Schilling, 2010) 40. Establishing Safety &Crisis ManagementAdvance collaborative planning: Help consumer to identify triggers for distress Help consumer to identify ways to safely calm downor self-soothe Provide resources for self-regulation(Schilling, 2010) 41. Creating a Safety Plan Collaborate with the individual to identify triggers and situations thatmay pose a threat to safety. Assist individual to identify coping skills- safe ones- that he/she hastried before successfully to manage a trigger. Facilitate discussion of additional skills that he/she would be willing toexplore as ways to manage triggers. Identify support people for contact in the case of crisis. Identify what actions are not helpful in the time of crisis. Emphasize emergency crisis plan with emergency phone numbers andidentification of hospital if needed. 42. EstablishingSafety & Crisis ManagementAssist agitated consumers in a non-aggressive & non-threatening manner Stay calm Make eye contact Keep appropriate physical distance Be respectful and non-judgmental Offer options Focus on de-escalation not winning vs. losing(Schilling, 2010) 43. What Helps with Upset Consumers Be calm Listen, validate, allow to ventilate Determine whether there is an actual emergency If there is- deal with that Offer options Give clear information and suggestions If no emergency, what does the consumer want to addressright now? Help consumer to focus on realistic plan of action(Schilling, 2010) 44. Helpful Coping Skills Grounding Self-soothing Making safer choices Information(Schilling, 2010) 45. Trauma and RelationshipRecognize that since trauma mostoften occurs in relationship, healing andrecovery must also occur in relationship.(Schilling, 2010) 46. Trauma and RelationshipSince trauma occurred in relationship,healing occurs by changing the elements of relationshipFrom abusive to nurturingFrom unresponsive to empathicFrom lies and denial to authenticity and honestyFrom controlling to empowering(Schilling, 2010) 47. The Role of Power in theProvider Relationship In traditional case management paradigms, power and controlare held by the staff. The term case management hasimplications that contradict core principles of TIC. In TIC service systems, power and control are held by theconsumer: Collaboration and cooperation are central concepts Staff and consumer collaborate on service plans, housingarrangements, financial decisions and medication orders Staff empower the consumers voice rather than silencing it(Harris & Fallot, 2001) 48. Collaboration Follow the consumers lead on current goals, needs and wants. Present options for services and respect the consumers choices. Assist the consumer to learn self-advocacy and promote involvement inservices as well as sharing concerns regarding services. Involve consumers in planning of services. Use Motivational Interviewing techniques. 49. Strengths-Based Approach Highlighting the assets of the consumer in the assessment andintervention helps empower the consumer to connect withresilience and hope. Focus on positive steps towards change and notice periods ofsuccess and factors that contributed to success. 50. Self-Care & Wellnessfor the Clinician 51. The Challenges of Working With ThoseAffected by Trauma Burnout Compassion Fatigue Vicarious Trauma 52. Impact of Trauma Work Can alter the clinicians view of the world and other people.May lead to pessimism and cynicism. Decreased feelings of safety. Increased paranoia orquestioning of others intentions. Clinician may become overly concerned with safety of self andconsumers or may become numb to sense of danger and misssigns of risky behavior for self or consumers. Can affect clinicians connection to others and relationshipwith spiritual beliefs. Decreased sense of hope. Physical and emotional exhaustion.(Harris & Fallot, 2001) 53. Risks for IncreasedTrauma Work Impact Working solely with consumers affected by trauma Working in an agency that does not support trauma-informed care Lack of understanding about trauma dynamics and typicaltrauma-related behaviors Clinician history of trauma May overextend self to help survivors May expect others to follow same recovery steps May not be aware of own trauma history and unconsciouslydeny or avoid exploring trauma 54. Possible Work Factors that Increase the Impact ofTrauma Work Work with consumers where concrete signs of success may befew Consumers with few resources and multiple problems Exposure to complex consumer situations Consumers who are difficult to engage Lack of community and organizational resources Not enough recovery time between client meetings Lack of recognition of the impact of trauma work asoccupation risk of the type of work being done Poor recognition of the value of the work being done Time pressures and paper workload Exposure to possible unsafe work situations(Rose, 2007) 55. Possible Individual Factors that Increase theImpact of Trauma Work Personal history Personality Current personal circumstances Level of professional development High ideals/ rescue fantasies/ over-investment in meetingall of clients needs. Those most vulnerable to ITW mayview themselves as saviors or rescuers Working without supervision and/or consultation Poor support network Personal style of coping(Figley, 1995; Rose, 2007) 56. Individual Ways to Reduce the ITW Psychological: Sustain balance between work and play Effective relaxation time and methods Using meditation or spiritual practice that iscalming Self assessment and self awareness Frequent contact with nature or other calming stimuli Methods for creative expression(Rose, 2007) 57. Individual Ways to Reduce the ITW Physical: Body work: Monitoring parts of your body for tension andusing methods to release tension Healthy sleep schedule Healthy nutrition(Rose, 2007) 58. Individual Ways to Reduce the ITW Social/Interpersonal: Social supports: At least 5 people, including 2 at work, whowill be highly supportive when called on Getting help: Knowing when and how to access help, bothinformal and formal Social activism: Being involved in social justice activities toaddress injustice(Rose, 2007) 59. Inventory of Self-Care Balance between work and home Boundaries/limit setting Time boundaries/ monitor overworking Personal boundaries Professional boundaries Dealing with multiple roles Realistic sense of things you can change and acceptingthose you can not(Rose, 2007) 60. Inventory of Self-Care Getting help and support at work Peer support Supervision Consultation Role models/ mentors Increasing work satisfaction: Remember the joys and achievements Count the small steps towards success(Rose, 2007) 61. Wisdom for the JourneyHope is not believing that we can change things.Hope is believing that what we do makes a difference.Vaclav Havel 62. Tim Welsh LCSWtwelsh@fhclouisville.org502 569 1662 63. Trauma ScreeningTrauma screening refers to abrief, focused inquiry to determinewhether an individual has experiencedspecific traumatic events.(Harris & Fallot, 2001) 64. Trauma ScreeningTwo primary factors contribute to trauma concernsbeing overlooked: Under-reporting of trauma by survivors Under-recognition of trauma by providers(Harris & Fallot, 2001) 65. Under Reporting of Trauma Immediate safety concerns (i.e. fear of retaliation fromabusers) May fear stigma or responses that disbelieve or blamethe victim or pathologize attempts to cope with trauma Some feel ashamed about being victimized and theattached sense of weakness Some, especially men, withdraw and isolate Childhood experiences may not be clearly remembered(Harris & Fallot, 2001) 66. Under Recognition of Trauma Providers may feel uncomfortable asking abouttrauma, fearing that they will not be able to manage theresponse Providers may not want to ask because of lack of services toaddress trauma concerns Providers may use vague or unclear terms that do notcorrespond to consumers experience of past trauma (i.e.violent physical abuse may be understood to have beendiscipline)(Harris & Fallot, 2001) 67. Reasons for Trauma Screening A main purpose is to identify effective follow-up andreferral, including determining need for immediate response ifrisk of imminent danger exist. Screening demonstrates that agency identifies violence andabuse as important events in the consumers life and that staffare comfortable discussing trauma with consumers. Even if consumer declines to report, staff have initiated theconversation and increased likelihood that consumer mayrevisit trauma concerns later.(Harris & Fallot, 2001) 68. Basics of Trauma Screening Adequate consumer and clinical preparation Establish safety Look at individual needs and contextual issues Follow consumer cues on whether to proceed Explain rationale for questions Ask permission to ask and give permission to pass/end Limit screening to several questions Preparation for limited disclosure initially Be clear and straightforward Consider self-administered questionnaire(Harris & Fallot, 2001) 69. Basics of Trauma Screening Complete screening with discussion of implications forresources. Express appreciation for consumer participation and/orconsumer ability to self-protect by passing on questions orending discussion. Provide education and information regarding impact of traumaas well as emphasize ability to heal from trauma as well asresilience.(Harris & Fallot, 2001) 70. Adverse Child Experiences Study(ACE www.acestudy.org)