from “in their own words: trauma survivors and professionals they trust tell what hurts, what...
TRANSCRIPT
"With abuse, you suffer loss of soul, loss of self and loss of meaning."
"In the system, you must fight every day, every minute, to keep from feeling worthless - to keep your spirit
alive." K.W. (Survivor)
From “In Their Own Words: Trauma survivors and professionals they trust tell what hurts, what helps, and what is needed for trauma services” (1997) Jennings, A. and Ralph, R.
Non-CompliantTreatme
nt-Resistan
t
Taking responsibility for failing to better help a client, or for not knowing what to do or how to understand.
Clients are “splitting”
staff.
Staff taking responsibility for splitting themselves. Most of what passes for "splitting" is simply the person asking different people for what she/he wants, hoping for an alternative answer or an ally. "Your history follows you no matter what you do in the present. I
only got assaultive one time and that was when they tore the head off my stuffed doll that I had had for a lifetime. Now providers tell me I'm dangerous and I terrify people. My history follows me.”I got traumatized because of trusting people, and asking me to make a contract with you demands I trust you - which I can't.
We know what works for us and what we need, but no one will listen or take us seriously.
Objectives
Describe the difference in trauma informed care and trauma specific services.
Give at least three examples of the impact of prolonged or complex trauma/ stress on emotions, thinking and our physical self.
Describe how adverse childhood experiences are connected to adult health and wellness.
Reframe a behavior using a trauma lens and be able to articulate at least one “Trauma Education Statement”.
Define the differences in burnout, vicarious trauma, secondary traumatic stress, compassion fatigue and countertransference.
Identify one strategy they use or can use to reduce workplace stress/trauma.
Identify ways their program provides safety, power and value to service users and staff.
Identify hotspots for retraumatizaion in their program for service users and staff.
Trauma Informed Care
“Trauma-informed organizations, programs, and services are based on an understanding of the vulnerabilities or triggers of trauma survivors that traditional service delivery approaches may exacerbate, so that these services and programs can be more supportive and avoid re-traumatization.” (SAMHSA)
Trauma Specific vs Trauma Informed
Trauma Recovery/Trauma Specific Services Reduce symptoms Promote healing Teach skills Psycho-empowerment, mind-body, other modalities.
Trauma Sensitive Bring an awareness of trauma into view Trauma lens
Trauma Informed Care Guide policy, practice, procedure based on understanding of trauma Assumption: every interaction with trauma survivor activates trauma
response or does not. Corrective emotional experiences. Parallel process
What is Trauma?
Can be single event. More often multiple events, over
time (complex, prolonged trauma).
Interpersonal violence or violation, especially at the hands of an authority or trust figure, is especially damaging.
Why Now? Is it a Fad?
Developmental neuroscience, interpersonal neurobiology.
Enormous advances in neurobiology in the last two decades, brain imaging.
Adverse Childhood Experiences Study (Kaiser
& CDC) Link with mental, behavioral, and physical
outcomes Compelling evidence for a public health perspective
Why is it important?
Trauma is pervasive.
Trauma’s impact is broad, deep and life-shaping.
Trauma, especially interpersonal violence, is often self-perpetuating.
Trauma differentially affects the more vulnerable.
Trauma affects how people approach services.
The service system has often been retraumatizing.
Prevalence in High Risk Populations
High rates of sexual/physical assault among women with substance abuse challenges (up to 99%).
Link between substance abuse and domestic violence (up to 80% co-occurrence among women).
Sex work and trauma history (up to 99%)
Public mental health clients and histories of trauma (up to 90%, most with complex trauma). Childhood trauma especially linked with Borderline
Personality Disorder, Dissociative Identity Disorder.
Studies from a number of psychological journals report that between 75-93 percent of youth entering the juvenile justice system annually are estimated to have experienced some degree of traumatic victimization. A study of children held in a Chicago detention center found that over half of them
had experienced more than six traumatic events prior to their detainment.
Males who experienced maltreatment prior to 12 years of age, 50-79 percent became involved in serious juvenile delinquency.
Young boys engaged in sexual offenses, 95 percent reported some type of trauma exposure, 77.5 percent reported more than one type of trauma and nearly half had experienced both physical and sexual abuse.
Incarcerated women were more likely to report a history of childhood sexual or physical abuse.
That most pre-teen and adolescent youth who participated in a homicide offense have histories of severe childhood maltreatment.
http://www.justicepolicy.org/images/upload/10-07_REP_HealingInvisibleWounds_JJ-PS.pdf37
Prevalence of Trauma in Community Samples
NVAW Survey (NIJ, 1995-96) 52% of women report lifetime history of physical
assault; 66% of men. 18% of women reported rape or attempted rape at
some time, many before age 18. 22% of women reported domestic violence; 7% of men.
Adverse Childhood Experiences study (CDC, 1995) 17,337 Kaiser enrolled adults ACE score cumulative based on 10 experiences in
childhood. Includes but not limited to violent trauma.
What it doesn’t mean
It doesn’t mean excusing or permitting/justifying unacceptable behavior Supports accountability, responsibility
It doesn’t mean just being nicer Compassionate care vs. TIC Compassionate yes, but not a bit mushy
It doesn’t ‘focus on the negative’ Skill-building, empowerment Recognizing strengths
Principles of Practice
With a foundation of awareness and understanding, organizations can strive to reflect three central principles of TIC, by creating policies, procedures, and practices that:
create safe context, restore power, and value the individual.
Trauma Informed Care (TIC) recognizes that traumatic experiences terrify, overwhelm, and violate the individual. TIC is a commitment not to repeat these experiences and, in whatever way possible, to restore
a sense of safety, power, and worth
Commitment to Trauma Awareness Understanding the Impact of Historical Trauma
Create Safe Contextthrough:Physical safetyTrustworthinessClear and consistent boundariesTransparencyPredictabilityChoice
Restore Power through:ChoiceEmpowermentStrengths perspectiveSkill building
Value the Individual through:CollaborationRespectCompassionMutualityEngagement andRelationship Acceptance and Non-judgment
Agencies demonstrate Trauma Informed Care withPolicies, Procedures and Practices that
Trauma Informed Care
So what do you need to know? It’s not going away.
Your staff/workforce are engaging with the material.
Trauma seems to convene
It lets us talk about Secondary Traumatic Stress (STS) and Vicarious Trauma (VT)
Gives power to workforce
Acute Trauma Response
When Trauma Happens….
Freeze, Flight, Fight, Fright
Chronic Trauma, Complex trauma overtime
Traumatic Stress – Toxic stress
How does this “look” in clients and in staff?
Brain Structures Involved…
Offers rational thinking, planning, decision making, sense making
If stress response warranted – HPA axis initiates
Illustration: Hallorie Walker Sands
Memory formation – checks memories for context
Considers sensory info for real or perceived danger
Incoming sensory information
Amygdala signals treat to hypothalamus – activates the HPA Axis kicking in hormones to protect the organism these include: Catecholamine – prevents rational thought Cortisol – give you energy to react Opiates “natural morphine” – to numb pain = flat affect Oxytocin – positive feelings
1. Hormonal soup causes blunt affect, high and lows,
2. Make memory consolidation and recall challenging
3. Tonic mobility happens - coulda shoulda wouldsa was actually not possible
If you can’t flee or fight your system goes on overload and “shuts down” = tonic immobility shown as, paralysis, trembling, incapacity to scream, numbness, sensation of cold , fear, feeling disconnected from oneself and surroundings
Neurobiology Take Aways Communication: Decreased verbal (left
hemisphere) – hypersensitive to nonverbal (right hemisphere) – prone to misinterpret.
Memory: Explicit memory (hippocampus) – facts, stories, pictures
– impaired Implicit memory (amygdala – acute trauma) often clear
and sharp
Hippocampus extremely sensitive to excess cortisol – resulting in memory problems that are long-term often permanent
Trauma generally impacts the limbic system Amygdala senses threat and results in a heightened
arousal/emotional state Frontal lobe (reasoning, thought) and left hemisphere
(spoken language) shut down
When amygdala senses threat, it creates emotional memories in response to particular sounds, images, and sensations it connects to a significant threat
Once amygdala is programmed to certain sounds,
images and sensations, it is likely to respond to those as a trigger
Chronic Stress- Trauma
Catecholamine- increased; damage memory, rational thought, hypervigilance, can’t distinguish danger signals
Corticosteriods – are low*; reduce immune functioning
Opiod - levels increase – flat affect
Oxytocin – increased, memory impaired, bound to oppressor
Complex Trauma
ACE Score Includes:
Lack of nurturance and support (emotional neglect).
Hunger, physical neglect, lack of protection (homelessness).
Divorce in the home.
Alcoholism or drug use in home.
Mental illness or attempted suicide among household members.
Incarceration of household member. Two-thirds of sample had a score
of 1 or more. More than 10% had score of 4 or more.
The Cumulative Impact
ACE study (scores 0-10) Score of 4 or more: ▪ Twice as likely to smoke ▪ 12 times as likely to have attempted suicide. ▪ Twice as likely to be alcoholic. ▪ 10 times as likely to have injected street drugs.
Score highly correlated with: ▪ Prostitution, mental health disorders, substance
abuse, early criminal behavior. ▪ Physical health problems, early death.
Adverse Childhood Experiences(www.ACEstudy.org)
Impact of Trauma Fight, Flight……….& Freeze Tend and Befriend (Taylor, et al)
Emotional Reactions Feelings – emotions, Regulation Alteration in consciousness Hypervigilance
Psychological and Cognitive Reactions Concentration, slowed thinking, difficulty with decisions,
blame Behavioral or physical
Pain, sleep, illness, substance abuse Beliefs
Changes your sense of self, others, world Relational disturbance
**pay attention to how this intersects with getting basic needs met
Our brains change and welcome change.
Positive interactions which communicate safety and connection are foundational to changing unproductive brain patterns.
Every interaction the survivor has with a provider system has the potential of adding to the trauma experiences, reactivation of trauma memories, or providing a sense of safety and enhancing
emotional regulation.
This is not the entire picture
Neurobiology helps us understand a piece Explains what we have known
Consider also culture, oppression, race as impacting and protecting
Societal messaging
It’s more than what it seems…….
Through A Trauma Lens
Sue successfully completed her substance abuse treatment program. Part of the safety plan for her to have her 4 y/o is no contact with her abuser. While out one day she runs into her ex-partner who was abusive. Her DHS worker finds out, confronts her about it and she doesn’t tell the truth saying “it never happened”.
You are meeting with Kiesha to complete paperwork for services she requested. She keeps rustling through her bag while your talking, looking outside your office, and checking her phone. She can’t seem to settle down and focus.
You are meeting with Yumi after an altercation with another youth. She quickly says it is not her fault, that the program is targeting her and the system is unfair.
Tim is completing an intake for your services. Your program has several rules and protocols that need to be followed to successfully complete. Tim’s referral states that he has difficulty with authority and following rules and doesn’t accept help from others.
Pat agrees to MH counseling in a team mtg but “no shows” for the intake. During follow-up she states she is very interested but “no shows” again.
Jack calls all of his providers, multiples times. The calls are often about the same thing. He is often asking for tangible goods & can be verbally aggressive. For example last week he called requesting bus tickets. One of his providers said “I think I can get you some” but he kept calling the other providers.
A Trauma Lens
1. What might the NON-Trauma Informed system say about this person?
2. What we know about trauma is because/to
1.2.3.
What we know about trauma is that trauma survivors often started using substances to either prevent feeling greater pain, to feel something, or because it was forced onto them.
Trauma Informed Care
The Foundation
Trauma Awareness Trauma education and training for all staff; Hiring, management, and supervision practices; Policies and procedures for referral, intake, termination; Recognition of vicarious trauma and the appropriate care of staff; Universal precaution and/or universal screening; Knowledge of effective trauma recovery services; Advocacy within the agency and with partner agencies/systems.
Understanding of the impact of historical trauma and all forms of oppression Ongoing training for all staff Ongoing inclusion of consumer voice Procedures and practices that promote and sustain accountability
Create Safe Context
Physical Safety What does it look like? Where and when are
services? Who is there/allowed to
come? Attend to unease.
Is there anything I can do to help you feel more safe?
Lighting Bathrooms Exits/entrances Signage about what to
expect, where to go… Home visiting plans. End with “whats next”
- predict Vicarious trauma
prevention plans Training Scripts
Create Safe Context cont… Emotional Safety
Clear & consistent boundaries▪ Be able to state and
model▪ Allowed to speak up
re: vicarious trauma Transparency▪ Explain the “why”▪ Eligibility written out
and explained Predictability▪ What next
What is your role? Saying no. Access to records Access to job
expectations before hire
Psy eval prep
Trigger Words…phrases
Concurrent planning Can I see you in my office –
Approach the bench Remember why we are here Trust Accountability Denies – refuses
Restoring Power
Empowerment Advocate, model May need to do for
first Choice
As much as possible 3 options
Strengths Perspective (trauma) Focus on the future
Skill building Every encounter
Learned Helplessness
3 choices
Relationships not used as threat
Frontal lobe
Value the Individual
Respect Life experience valued
Collaboration Referrals, teams,
meetings Compassion
Not an excuse but an explanation
Self Care Relationship
Modeling, boundaries, learning, partnering
Supervision
Structure to have voices heard
Acknowledgement
Giving voice to –
Advocating for
Examples:
Intake forms Rules that don’t have a “why” attached Assessing trauma & related skills Trauma education Scripts for response De-escalation protocols practices Vacation policies Hiring scenarios TIC statement from agency Food and water Ackowning who is in the room Check out procedures Home base person FEEDBACK Music in lobby
Our Work is to
Prevent re-traumatization – triggers How can you know?
Recognize early warning signs Know your work/population
Intervene – deescalate Multi-level – micro, macro
What difference does it make?
Consumers can participate in their own care.
Consumers (and staff) gain skills for self-
regulation and self-advocacy.
Consumers (and staff) can remain engaged
even when there are bumps in the road.
The work is more rewarding.
Vicarious trauma/worker stress is reduced.
A Culture of TIC
Involves all aspects of program activities, setting, relationships, and atmosphere (more than implementing new services).
Involves all groups: administrators, supervisors, direct service staff, support staff, and consumers.
Involves making trauma-informed change into a new routine, a new way of thinking and acting .
Commitment to an ongoing process of self-assessment, review, hearing from consumers and staff, openness to changing policies and practices.
Application:
Identify hotspots for retraumatization in your work.
Can you provide an example of how you attempt to have folks feel safe, feel empowered or feel valued?
Parallel Process
What is required to Provide TIC? Secure, healthy adults; Good emotional management skills; Intellectual and emotional intelligence; Able to actively teach and be role model; Consistently empathetic and patient; Able to endure intense emotional labor; Self-disciplined, self-controlled, and
never likely to abuse power.
See http://www.sanctuaryweb.com/
The Reality
We have a workforce that is under stress. We have a workforce that absorbs the
trauma of the consumers. We have a workforce populated by
trauma survivors. We have organizations that can be
oppressive. All of this has an impact
We have organizations that come to resemble the behavior we’re trying to help.
Concepts
Professional Burnout Multi-state exhaustion resulting from chronic exposure to
suffering – progressive, ind-pop-org; emotional exhaustion, depersonalization, reduced sense of accomplishment
Vicarious Trauma A process of cognitive change resulting from empathic
engagement with TS; change in sense of self and world – safety, trust, control, spiritual beliefs
Secondary Traumatic Stress Behaviors and emotions resulting from knowing about a T event
experienced by a significant other or helping a TS; PTSD Compassion Fatigue
Syndrome = combo of STS and PB Transference – countertransference
See Berzoff, J. & Kita, E. (2010).
Protective Factors
Team spirit See change as a result of your work Training Supervision Psychoeducation on these topics Balanced caseload SIT through education
See Berzoff, J. & Kita, E. (2010).
Risk Factors
Your history Consumers’ stories (CSA vs cancer) Always empathetic Lack of experience Workload Case load Isolation
Strategies
Reduce isolation – connecting with others Say hello to each other Peer consultation groups Knowledge – book groups – questions in
meetings Bring the positive back to consciousness Feedback from consumers Limit exposure Rituals Wellness – vicarious prevention plans