Trauma-Informed Care. Trauma. Define terms Recognize prevalence Understand impact 11/3/2013. Trauma Informed Care 1. Trauma-Informed Care

Transcription

1 Trauma-Informed Care Empowering. Engaging. Effective. First steps Trauma-Informed Care Define terms Recognize prevalence Understand impact 2 Trauma Refers to extreme stress that overwhelms a person s ability to cope Is subjective Often results in feeling vulnerable, helpless and afraid Often interferes with relationships and fundamental beliefs about oneself, others and one s place in the world 3 Trauma Informed Care 1

2 DSM-V Post Traumatic Stress Disorder Intrusion Avoidance Alterations in arousal and reactivity Negative alterations in cognitions and mood Posttraumatic Stress Disorder in Preschool Children 4 Trauma Continuum Acute Trauma Adult onset Single incident Adequate child development No co-morbid psychological disorders Complex Trauma Early onset Multiple incidents Extended over time Highly invasive Interpersonal Significant amount of stigma Vulnerability 5 Complex Trauma Emotional Cognitive Interpersonal Behavioral Dysregulation 6 Trauma Informed Care 2

3 Prevalence 56% of the general population reported at least one traumatic event. (Kessler,1996) 90% of mental health clients have been exposed to a traumatic event and most have multiple exposures. (Muesar,1998) 83% of females and 32% of males with developmental disabilities have experienced sexual assault. Of those who were assaulted, 50% had been assaulted 10 or more times. (Hand,1986) 97% of homeless women with mental illness experienced severe physical and/or sexual abuse. (Goodman et al.,1997) 8 Prevalence cont d Women in community samples report a lifetime history of physical & sexual abuse ranging from 36-51%, while women with substance abuse problems report a lifetime history ranging from 55-99%. (Najavits et. al., 1997) 75-93% of youth entering the juvenile justice system are estimated to have experienced some degree of traumatic victimization. (Healing Invisible Wounds, Justice Policy Institute) Evidence suggests that some communities of color have higher rates of PTSD than the general population. (SAMHSA, Strategic Initiative #2) 9 Trauma Informed Care 3

4 Youth 26% of students (33% male / 19% female) reported being in a physical fight 23% of students (22% male / 23% female) reported being bullied at school 21% of students (16% male / 26% female) reported symptoms of depression 13% of students (10% male / 16% female) reported seriously considering suicide (WI Youth Risk Behavior Survey, WI Dept. of Public Instruction, 2009) Most trauma begins at home: the vast majority of people (about 80%) responsible for child maltreatment are children s own parents. (van der Kolk, 2005) Universal Precautions Universal approaches address entire groups that share the same general risk. Universal strategies are applied to groups without any prior screening, when the entire group is capable of benefiting. (Miller, 2011) 11 Vicarious or Secondary Trauma Signs & Symptoms Cynicism Social withdrawal Physical problems Boundary problems Difficulty managing emotions Difficulty making decisions Problems in relationships Anger Increased use of alcohol, tobacco, food, etc. Risk Factors Personal history Life circumstances Personality & coping style Lack of social support Work setting Agency support Culture of intolerance Trauma Informed Care 4

5 Sanctuary Trauma The overt and covert traumatic events that occur in settings that are supposed to be safe: Foster care School Places of worship Boarding schools Medical, mental health & substance use disorder services Corrections 13 Historical Trauma Collective and cumulative emotional and psychological wounding across generations, emanating from massive group trauma. Generates survivor guilt, depression, low self-esteem, psychic numbing, anger, and physical symptoms. Creates the community s soul mood. (Maria Yellow Horse Brave Heart) 14 Epigenetics Scientists are discovering how stress experienced early in life can cause long-standing and generational changes in physiology and behavior. 15 Trauma Informed Care 5

6 More on the Impact of Trauma 16 Building Resilience Person Developmental mastery / Competence Strengths (e.g., intelligence, confidence, positive temperament, hope, empowerment, character) Coping strategies Environment Secure attachment to at least one caring adult / Sensitive and positive parenting Connections at school / community that create security and safety Sociocultural factors such as access to safety and resources, social justice, social cohesion Expectations of and for success Role models 17 Early Relationships Relationships are developed through the emotional bond between the child and caregiver. It is through this relationship that we learn to: Regulate emotions/self-soothe Develop trust in others Freely explore our environment Understand ourselves and others Understand that we can impact the world around us Begin to establish a worldview 18 Trauma Informed Care 6

7 Sequential Brain Development Infant Age 1-2 Age 2-3 Age Brainstem: Basic life functions Attachment Lower Brain: Arousal Sleep Attachment Midbrain: Emotional Reactivity Sexual Behavior Motor Regulation Empathy Cortex: Reasoning Problem Solving Affiliation In times of stress, we regress. Environmental Input Cortex Core relationship slower Propriocentric Vestibular Hippocampus Touch Taste Smell Sensory Thalamus Very Fast Amygdala Sound Sight Response LeDoux 1996 Primitive / Survival Responses Fight Flight Fright Freeze Flail Shield Flirt Submit 21 Trauma Informed Care 7

8 Reminders or Triggers Lack of or loss of control Threats/feeling threatened or attacked Observing threats/assaults Isolation Interacting with authority figures Lack of information Being told what to do Lack of privacy Removal of clothingmedical exams Being touched Being watched Loud noises Darkness Intrusive or personal questions Being locked in a room Being ignored Condescending looks 22 Reminders or Triggers, cont d Sensory experiences (e.g., smells, sounds, touch, taste, body position) Separation or loss Transitions and disruptions in routine Feelings of vulnerability and rejection Sensory overload (e.g., crowded spaces, loud sounds, powerful smells) 23 Impact on Worldview Typical Development vs. Belief in a predictable and benevolent world Positive self worth Hopeful and optimistic about the future Empowered Developmental Trauma Basic mistrust of others Belief that the world is an unsafe place Negative self-worth Fear and pessimism about future Hopeless and powerless 24 Trauma Informed Care 8

9 Explaining not Excusing Behaviors Outward Expressions Anger/defiance Violence toward others Truancy Criminal acts Perfectionism Inward Expressions Withdrawal Substance use Perfectionistic Violence to self Spacing out 25 Trauma-Informed Care (TIC) 26 I had been coerced into treatment by people who said they were trying to help These events 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. (Laura Prescott) 27 Trauma Informed Care 9

10 Trauma-Informed Care What it is A principle-based culture change process What it is not An intervention to address PTSD Move from What s wrong with you? to What happened to you? 28 Using Trauma Theory to Design Service Systems 5 Values Safety Trustworthiness Choice Collaboration Empowerment (Fallot and Harris, 2001) 29 Wisconsin s TIC Guiding Principles Healing happens in relationships (WI TIC Advisory Committee, 2009) 30 Trauma Informed Care 10

11 SAMHSA s TIC Guiding Principles Incorporate knowledge about trauma prevalence, impact, and recovery in all aspects of service delivery Physical and Emotional Safety Trustworthiness and Transparency Collaboration & Mutuality Empowerment Voice & Choice Peer Support and Mutual Self-Help Resilience and Strengths-Based Inclusiveness and Shared Purpose Cultural, Historical and Gender Issues Change Process (SAMHSA, 2012) 31 Fostering Futures TIC Guiding Principles Prevalence and Impact Safety and Relationships Consumer Engagement and Choice Integration of Care with a Holistic Approach Cultural Competence Secondary Trauma and Stress Range of Services 32 Practice Based on TIC Principles Principle: Consumer Engagement and Choice Business as Usual Everyone goes to bed at 10:30pm. Family is given completed treatment plan which must be signed for services. A few homogenous activities are offered; non-participation is viewed as non-compliance. Trauma-Informed Time for sleeping is adaptable and based on the child s needs. Recovery plans are created collaboratively with people involved in the child/family s life as chosen by the child/family. People are offered a menu of options based on needs, strengths, hopes and dreams. Non-participation is viewed as wrong fit / activity not meeting the needs of child/family. 33 Trauma Informed Care 11

12 More Comparisons Business as Usual Trauma-Informed Key Question: What s wrong with you? Symptom reduction Rules, directives, and use of token systems to maintain order Therapy sessions viewed as the primary and often sole healing approach Key Question: What happened to you? Symptoms are adaptations to trauma. Wellness plans, stress reduction are among many tools used to recover Healing can happens in healthy relationships 34 What Can You Do? Assume a trauma history whether or not child/family discloses or remembers trauma. Understand problem behaviors as survival strategies that served a safety function and view these as evidence of strength and resiliency. Develop TIC relational skills. Create safe and predictable environments and relationships. Provide education and information about trauma as part of your everyday activities. Empower people to change long held beliefs and coping strategies. 35 TIC and Organizational Change Leadership and Champions Meaningful client involvement Trauma-sensitive human resource practices Trauma-sensitive environment Trauma-sensitive strategies and tools 36 Trauma Informed Care 12

13 DHS TIC Website Logic model State activities Resources List serve sign up 37 General Trauma Resources National Center for Trauma-Informed Care National Center for Posttraumatic Stress Disorder National Child Traumatic Stress Network International Society for Traumatic Stress Studies International Society for the Study of Trauma and Dissociation The Anna Institute 38 School Specific Resources Creating Sanctuary in Schools Creating Trauma Sensitive Schools Child Trauma Toolkit for Educators - NCTSN Helping Traumatized Children Learn The Heart of Learning & Teaching Compassion, Resiliency & Academic Success Trauma Informed Care 13

14 Questions? Elizabeth Hudson, LCSW Consultant to the WI Dept. of Human Services If you would like to be added to the Wisconsin TIC List Serve, please follow this link: 40 Trauma Informed Care 14