diane smylie substance use knowledge exchange leader [email protected]
TRANSCRIPT
Trauma-informed Practice (TIP)what is it? why is it important? what can you do?
Diane Smylie
Substance Use Knowledge Exchange Leader
PHSA – Nursing January 28, 2015
Background
• Provincial TIP initiative (TIP Guide & Curriculum)• Regional work supported by provincial KE Team (DTFP)• Current work at BC Mental Health and Substance Use
Services – Children and Women’s programs
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Breathe
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What? Why? & How?
• Defining trauma
• Prevalence and links to health and mental health
• The rationale for trauma-informed practice
• Basic trauma-informed practice concepts and definitions• TIP resources and examples of how TIP is being
implemented in various service contexts
PHSA – Nursing January 28, 2015
PREVALENCE & LINKS
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Trauma and PTSD
The terms violence, trauma, abuse, and post-traumatic stress disorder (PTSD) often are used interchangeably. One way to clarify these terms is to think of trauma as a response to violence or some other overwhelmingly negative experience (e.g., abuse).
Trauma is both an event and a particular response to an event. The response is one of overwhelming fear, helplessness, or horror. PTSD is one type of disorder (response) that results from trauma.
(Covington, 2003)
PHSA – Nursing January 28, 2015
Definition of Historical Trauma
“The cumulative emotional and psychological wounding across generations, including the lifespan, which emanates from massive group trauma”
“When cumulative HT events are coupled with high rates of contemporary lifetime trauma and interpersonal violence, as well as high rates of chronic stressors, such as daily discriminatory events, together, these historical and contemporary events undermine physical, spiritual, and psychological health and well-being in complex and multifaceted ways.
Dr. Maria Yellow Horse Brave Heart, 2003
Walters et al., 2011
PHSA – Nursing January 28, 2015
Trauma is commonamong Canadians
In a representative Canadian sample, 76.1% of Canadians had
been exposed to at least one traumatic event in their
lifetime, 9.2% met the criteria for PTSD in their life time. (Van
Ameringen, Mancini, Patterson & Boyle, 2008)
PHSA – Nursing January 28, 2015
Trauma is common among people with mental health & substance use concerns
• Majority of adults and children in inpatient psychiatric and substance use treatment settings have trauma histories (Lipschitz et al, 1999; Suarez, 2008; Gillece, 2010)
• Survey of teens in substance use treatment > 70% had history of trauma exposure (Suarez, 2008)
• 2/3 adults in substance use treatment report child abuse and neglect (SAMHSA, CSAT, 2000)
SAMHSA, 2012
PHSA – Nursing January 28, 2015
What is Trauma?
• It can be a single event• Often multiple events over time (complex, prolonged
trauma)• An interpersonal violence or violation, especially at the
hands of an authority/trust figure is especially damaging • Trauma occurs in an interaction of person by event by
context (Harvey & Tummala-Narra)
PHSA – Nursing January 28, 2015
What does trauma do to us?
Chronic trauma interferes with neurobiological development and the capacity to integrate sensory, emotional and cognitive information into a cohesive whole.
Developmental trauma sets the stage for unfocused responses to subsequent stress.
Bessel A. van der Kolk , MDhttp://www.traumacenter.org/products/pdf_files/Preprint_Dev_Trauma_Disorder.pdf
PHSA – Nursing January 28, 2015
Trauma EffectsPhysical Emotional or
CognitiveSpiritual Interpersonal Behavioural
Unexplained chronic pain or numbness
Stress-related conditions (e.g., chronic fatigue)
Headaches
Sleep problems
Breathing problems
Digestive problems
Depression
Anxiety
Anger management
Compulsive and obsessive behaviours
Dissociation
Being overwhelmed with memories of the trauma
Difficulty concentrating, feeling distracted
Fearfulness
Emotionally numb/flat
Loss of time and memory problems
Suicidal thoughts
Loss of meaning, or faith
Loss of connection to: self, family, culture, community, nature, a higher power
Feelings of shame, guilt
Self-blame
Self-hate
Feel completely different from others
No sense of connection
Feeling like a ‘bad’ person
Frequent conflict in relationships
Lack of trust
Difficulty establishing and maintaining close relationships
Experiences of re-victimization
Difficulty setting boundaries
Substance use
Difficulty enjoying time with family/friends
Avoiding specific places, people, situations (e.g., driving, public places)
Shoplifting
Disordered eating
Self-harm
High-risk sexual behaviours
Suicidal impulses
Gambling
Isolation
Justice system involvement
Haskell, 2003; Haskell, 2001; Schachter et al., 2009
ACE’s Study
Mechanisms by which Adverse Childhood Experiences influence Health and Well-being throughout the lifespan
Felitti & Anda, 2010
conception
Death
If not disrupted
PHSA – Nursing January 28, 2015
WHAT DOES THIS MEAN FOR HEALTHCARE SETTINGS/PROVIDERS?
Trauma Awareness
Consideration of the profound neurological, biological, psychological & social effects of trauma & violence on all of us.
For more information on the neurobiology of
trauma:
www.childtrauma.org
www.traumacenter.org
Margaret E. Blaustein PhD. & Kristine M. Kinniburgh LICSW
“In many cases, people who endured childhood abuse and neglect develop what might seem like a bewildering array of problems throughout their lives.
Many service providers, and in many cases the survivors themselves, can misunderstand these difficulties as self-inflicted because they do not understand how abuse, trauma and their effects reverberate throughout a person’s life.” Haskell in Poole et al. 2012
PHSA – Nursing January 28, 2015
Issues affecting service access & engagement• Service entry points and transitions can be difficult to navigate• Services often lacking coordination and collaboration• Service settings and processes can be confusing• Service providers can have a tendency to reduce people to
labels (risky behaviors/ people)• Services sometimes prioritize provider needs /routines• Physical settings can be unwelcoming
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Trauma effects that can affect engagement
• Difficulty with trust and relationships• Reluctance to engage and quick to drop out• Vigilance and suspicion • Previous traumatic experience caused by health care
system/providers• Ambivalence to give up or change coping mechanisms• Current violence/trauma – lack of agency
Harris & Fallot, 2006
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What is “Re-traumatization”
• A situation, attitude, interaction or environment that replicates the events or dynamics of the original trauma and triggers the overwhelming feelings and reactions associated with them– Can be obvious or not so obvious– It is usually unintentional– It is always harmful – often exacerbating the very
symptoms that people are seeking help for
Jennings, 2013Retrieved from: theannainstitute.org
WHAT ABOUT THE PEOPLE PROVIDING THE SERVICES?
How are our values and assumptions affecting people?
Are we sometimes overwhelmed or triggered?
How does this affect our interactions with colleagues?
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TRAUMA-INFORMED & TRAUMA SPECIFIC PRACTICES
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Trauma-informed
• Value based with core principles
• Embed principles in all aspects of service
• Awareness of connections between trauma, mental health, substance use and health
• Universally offered
• Cultures of non-violence, learning and collaboration
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TIP Key Principles
1. Trauma Awareness
2. Emphases on safety and trust-worthiness (includes cultural safety)
3. Opportunity for choice, collaboration and connection
4. Strengths based and skill building
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Trauma specific services
• Offered in a trauma-informed environment• Focus on treating trauma through therapeutic
interventions• Specialized skills• Offered with consent to people who choose trauma
specific treatment• Based on a detailed assessment
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IN ACTION
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TIP can be seen in a change in the way we view people
Shift from: “What is wrong” to “What happened”
Change in language away from:
• Controlling
• Paranoid
• Manipulative
• Uncooperative
• Attention seeking
• Drug seeking
• Not believable, etc.
Nancy Poole, 2011
From… To…Controlling The individual seems to be trying to
assert their power
Manipulative The individual has difficulty asking for what they want
Attention seeking The individual is trying to connect the best they can
Symptoms Adaptations
Borderline The individual is doing their best given their early experiences
Malingering The individual is seeking help in a way that feels safer
Reframing Language
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Physical Environment
Consider:• Signage with welcoming messages, avoiding “do not”
messages • Waiting areas - comfortable and inviting• Lighting in outside spaces• Accessibility and safety of washrooms• In counselling rooms – choice about whether door is
open or closed
Fallot & Harris, 2009, &Ontario Guidelines, 2013
culturalcompetency.ca
PHSA – Nursing January 28, 2015
A Story of Change
"At first, it was hard to see if attending the course made much of a difference in my day to day work. I learned a
lot but was trying to figure out how it would help me in an ER. While thinking about this, I couldn't help but see
stigma against people with mental health AND addiction problems everywhere. It was like it was always there but
I couldn't see it. The hardest part for me was that I couldn't not see, especially with colleagues that I had come to
admire. The disapproving glances, the sighing and rolling of the eyes, the ignoring and running away, the
interrupting and telling people what to say and do before they even had a chance to understand what was
happening to them - the name calling - 'bed cloggers, frequent flyers - and even 'human waste' is used as code. It
became too much to handle and I was being traumatized by my coworkers. I took a chance and confided in
another nurse who had also taken the CAP course and she felt the same. Then, we reached out to another CAP
graduate and then we are three. We started to build confidence in our way of engaging with all people with
genuine concern and attunement. Slowly, we became know as the 'bleeding hearts' and we wear that badge
proudly. When we heard about TIP, we jumped at the chance to be part of the appreciative inquiry and that even
built our confidence more. You see working in an ER isn't so much about the patients, its about working around a
burned out staff and trying to fit in."
PHSA – Nursing January 28, 2015
TIP Organizational Culture
• non-violence
• emotional intelligence
• inquiry and social learning
• democracy
• open communication
• social responsibility
• growth and change
Bloom, 2005
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Self awareness & compassion for all…
www.youtube.com/watch?v=AHzvlMUoUYE
Moments to Milestones: Engaging with People who use Substances
This 30-minute video is intended as an education resource for first responders, including police, paramedics and emergency room staff. Also, this video has relevance for anyone working with people who use substances. It illustrates the remarkable, positive difference that can be made when people who use substance are approached in an attuned manner that fosters respect, compassion and inclusion.
PHSA – Nursing January 28, 2015
Examples of what’s happening in BC
• Vancouver Coastal Health – TIP Champions• BC MHSUS – Children’s & Women’s programs• Cross health authority MHSU dialogues (
[email protected] if interested)
• Provincial virtual CoP site• Appreciative inquiry with interested teams and groups• MCFD is developing a supplementary TIP Guide
Funding for this event has been provided in part by the Government of Canada, through British Columbia’s Drug Treatment Funding Program - Strengthening Substance Use Systems Initiative. The views expressed herein do not necessarily represent the views of the Government of Canada
PHSA – Nursing January 28, 2015
Questions?