Transcript Setting the Stage - Wisconsin United for Mental Health

Trauma-Informed Care
Empowering. Engaging. Effective.
Joann Stephens
Stable Life, Inc.
Trauma-Informed Care
What it is: a philosophical shift
What it is not: an intervention to
address PTSD
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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 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
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 traumarelated distress as a result of this exposure
Adverse Childhood Experience (ACE) Study
http://www.acestudy.org/
http://www.cdc.gov/nccdphp/ACE/
‘ACE’
Abuse
Household with:
• Psychological (by
parents)
• Substance abuse
• Physical (by parents)
• Mental illness
• Sexual (anyone)
• Separation/divorce
• Physical neglect
• Domestic violence
• Emotional neglect
• Imprisoned household
member
ACE Score = Trauma “Dose”
Number of individual types of adverse childhood
experiences were summed…
ACE score
0
1
2
3
4 or more
Prevalence
32%
26%
16%
10%
16%
As ACEs , problems :
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alcoholism and alcohol abuse
illicit drug use
risk for intimate partner violence
eating disorders
multiple sexual partners
smoking
suicide attempts
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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:
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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
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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:
What you may not see:
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Nothing
Laughter
Shut down / numb
Others?
Confusion
Guilt / Shame
Fear
Others?
Potential Triggers
• Lack of controlpowerlessness
• 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
E
Past
e
Present
E - A Large Event
e - A Small Event
R - A Large Reaction
R
Complex Trauma – Impact on
Development
Impact on Worldview
Typical Development vs. Developmental Trauma
• Nurturing & stable
attachments with adults
• Belief in a predictable &
benevolent world/
generally good things will
happen to me
• Feeling of positive selfworth /others will see my
strengths
• Optimism about the future
• Feeling that I can have a
positive impact on the
world
• 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
Understanding Behaviors:
Explanation vs. Excuse
• External defense
– Anger / defiance
– Violence towards
others
– Truancy
– Criminal acts
• Internal defense
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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
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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 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)
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
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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:
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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
Trauma- Informed
Key Question: ‘What’s Key Question: ‘What
wrong with you?’
has happened to you?’
Service providers are
the experts on the
lives of consumers
Therapy sessions and
specific interventions
are viewed as the
primary method of
treatment
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
Trauma-Informed
 Decreasing symptoms
viewed as success
 Symptoms viewed as
adaptations and ways to
cope to trauma.
Healing process may
temporarily worsen
symptoms
 Rules, directives, and use
of token systems as
primary approaches to
maintaining order
 Motivational interviewing,
lower brain interventions,
and compassionate
communication are tools
used to maintain healing
relationships
Practice Based on TIC Values
Value: Pursue the person’s strengths, choice and autonomy
TRADITIONAL
TIC
1. Everyone goes to bed at 10:30 pm
and lights out
1. A range for bedtime that identifies and
adapts to individuals difficulty with
night-time, bedrooms, and different
bio-rhythms
2. Person is given completed
treatment plan which must be signed
for services
2. Recovery plans are created
collaboratively; family members or
advocates are included if the consumer
so chooses
3. A few homogenous activities are
3. A variety of activities are offered and
provided and everyone is supposed to
consumers are provided a menu of
attend
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
Outcomes
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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:
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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, LCSW
Trauma-Informed Care Consultant
WI Dept. of Human Services
Division of Mental Health and Substance Abuse Services
608-266-2771
[email protected]
Employed by University of Wisconsin School of Medicine and Public Health