TRAUMA INFORMED PRACTICE. Diane Smylie

Transcription

1 TRAUMA INFORMED PRACTICE Diane Smylie

2 INTRODUCTION Background Sharing information and experiences to inform people as they respond in their own community contexts Truth and reconciliation hearings Challenges Opportunities The topic of trauma

3 DEFINITIONS

4 TRAUMA Experiencing, witnessing, or being threatened with an event or events that involve serious injury, a threat to the physical integrity of one s self or others, or possible death. The responses to these events include intense fear, helplessness, and/or horror. Women s Co-occuring Disorders and Violence Study Interpersonal trauma is defined as experiences involving disruption in trusted relationships as the result of violence, abuse, war or other forms of political oppression, or forced uprooting and dislocation from one s family, community, heritage, and/or culture Berman, Mason et al 2010

5 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)

6 HISTORICAL TRAUMA (HT) The cumulative emotional and psychological wounding across generations, including the lifespan, which emanates from massive group trauma Dr. Maria Yellow Horse Brave Heart (Hunkpapa Lakota), 2003 An event or set of events perpetrated on a group of people who share a specific group identity, with genocidal or ethnocidal intent. Individually, each event is profoundly traumatic; taken together they constitute a history of sustained cultural disruption and destruction. 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. Karina Walters (Choctaw), 2003

7 INTERGENERATIONAL TRAUMA Intergenerational or multi-generational trauma happens when the effects of trauma are not resolved in one generation. When trauma is ignored and there is no support for dealing with it, the trauma will be passed from one generation to the next. What we learn to see as normal, when we are children, we pass on to our own children. The unhealthy ways that people use to protect themselves can be passed on to children, without them even knowing they are doing so. (Aboriginal Healing Foundation, 1999:A5)

8 POST TRAUMATIC STRESS DISORDER DSM IV TR (V COMING SOON) Criterion: A. Experiencing or witnessing an event that threatened death or severe injury to self/other; B. Intrusive recollection/re-experiencing e.g. nightmares, flashbacks C. Avoidant/numbing e.g. detachment, avoiding people and/or places D. Hyper-arousal e.g. hyper-vigilance, difficulties with sleeping and/or concentrating E. Duration of disturbances is more than one month F. Causes significant problems with daily functioning APA, 2000

9 TRAUMA-INFORMED PRACTICE & KEY PRINCIPLES

10 TRAUMA INFORMED AND TRAUMA SPECIFIC Trauma-informed services: Embed an understanding of trauma in all aspects of service delivery Place priority on trauma survivor s safety, choice and control Create a treatment culture of nonviolence, learning, and collaboration Trauma-specific services: Directly address the impact of trauma Directly facilitate trauma recovery and healing Poole, 2011

11 TRAUMA INFORMED & TRAUMA SPECIFIC Trauma informed services Are informed about trauma, and work at the client, staff, agency and system levels from the core principles of trauma awareness, safety and trustworthiness, choice and collaboration, and building of strength and skills The connections between trauma, mental health substance use are discussed in the course of work with all clients, trauma symptoms/adaptations are identified, and supports and strategies offered that increase safety and support connection to services. Trauma specific services Are offered in a trauma informed environment, and are focused on treating trauma through therapeutic interventions involving practitioners with specialist skills. Offer services to clients with trauma, mental health, and substance use concerns who seek and consent to integrated treatment, based on detailed assessment. BC Trauma-Informed Practice Guide, 2013

12 All services taking a trauma-informed approach begin with building awareness among staff and clients of: The high prevalence of trauma How the impact of trauma can be central to one s development The wide range of adaptations people make to cope and survive The relationship of trauma with substance use, physical health and mental health concerns. 4 Key Principles 1.Trauma Awareness This knowledge is the foundation of an organizational culture of trauma-informed care BC Trauma-Informed Practice Guide, 2013

13 Trauma Survivors: Likely have experienced boundary violations and abuse of power Need to feel physical and emotionally safe May currently be in unsafe relationships Safety and trustworthiness are established through: Welcoming intake procedures Adapting the physical space Providing clear information and predictable expectations about programming Ensuring informed consent 4 KEY PRINCIPLES 2. Emphasis on safety and trustworthiness Creating crisis plans Providing culturally competent care/service BC Trauma-Informed Practice Guide, 2013

14 Service Providers: The safety and mental health needs of service providers are also considered within a trauma-informed service approach. Key component of Service Provider safety: Education and support related to vicarious trauma. 4 KEY PRINCIPLES 2. Emphasis on safety and trustworthiness (Part 2) BC Trauma-Informed Practice Guide, 2013

15 Trauma-informed services create safe environments that foster a client s sense of efficacy, self-determination, dignity, and personal control. Service providers are encouraged to: Communicate openly Equalize power imbalances Allow the expression of feelings without fear of judgment Provide choices as to treatment preferences Work collaboratively 4 Key Principles 3.Opportunity for choice, collaboration and connection BC Trauma-Informed Practice Guide, 2013

16 Service providers: Help clients identify their strengths Further develop resiliency and coping skills (could be related to culture/identity) Teach and model skills for recognizing triggers, calming, centering and staying present Support an organizational culture of emotional intelligence and social learning Maintain competency-based skills, knowledge, and values that are trauma informed 4 Key Principles 4. Strengths based and skill building BC Trauma-Informed Practice Guide, 2013

17 Trauma-informed services create safe environments that foster a client s sense of efficacy, self-determination, dignity, and personal control. Service providers are encouraged to: Communicate openly Equalize power imbalances Allow the expression of feelings without fear of judgment Provide choices as to treatment preferences Work collaboratively 4 Key Principles 3.Opportunity for choice, collaboration and connection BC Trauma-Informed Practice Guide, 2013

18 TRAUMA AWARENESS Prevalence Effects of Trauma Links with health

19 TRAUMA IS COMMON AMONG CANADIANS & PEOPLE WITH MENTAL HEALTH AND SUBSTANCE USE PROBLEMS 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 (Van Ameringen, Mancini, Patterson & Boyle, 2008) For women in treatment for alcohol problems at 5 Canadian treatment centres: 90% indicated abuserelated trauma as a child or adult, and 60% indicated other forms of trauma (Brown, Petite, Haanstra & Stewart, 2009) In a cohort of young people (14-30 yr) of Aboriginal descent who used injection and non injection drugs in Vancouver or Prince George, 48% reported ever experiencing sexual abuse (Pearce et al., 2008) Out of 102 patients with schizophrenia, bipolar disorder, or schizoaffective disorder, 47.5% of these patients had experienced childhood trauma (Alvarez et al, 2011)

20 POST-TRAUMATIC STRESS DISORDER PRIMARY CARE PTSD SCREEN (PRINS, OUIMETTE, KIMERLING ET AL., 2003) In your life, have you ever had any experience that was so frightening, horrible, or upsetting that in the past month you: a) had nightmares or thought about it when you did not want to? b) tried hard not to think about it or went out of your way to avoid situations that reminded you of it? c) were constantly on guard, watchful, or easily startled? d) felt numb or detached from others, activities, or your surroundings?

21 Percentage % POST-TRAUMATIC STRESS DISORDER (PTSD) P R I M A R Y C A R E P T S D S C R E E N ( P C - P T S D ) ( P R I N S, O U I M E T T E, K I M E R L I N G E T A L., ) Post Traumatic Stress Disorder, First Nations Adults, Hamilton Nightmares Avoided Trauma Startled by Trauma Detached/Numb "Positive" PTSD Score Our Health Counts Unmasking Health and Social Disparities among Urban Aboriginal People in Ontario Michelle Firestone Doctoral Thesis, Dalla Lana School of Public Health University of Toronto, 2012

22 THE EFFECTS OF TRAUMA/VIOLENCE/ABUSE Are often enduring and profound May shape every aspect of a person s life, even years after the traumatic experience has occurred Are particularly traumatic when the violence is ongoing, begins in childhood and is perpetrated by someone the person loves and should be able to trust (Haskell, 2008)

23 EFFECTS OF TRAUMA Physical Emotional Spiritual Interpersonal Behavioural unexplained chronic pain stressrelated conditions (i.e. chronic fatigue) headaches sleep problems breathing problems digestive problems depression anxiety compulsive and obsessive behaviours overwhelmed with memories of the trauma difficulty concentrating fearful emotionally numb loss of time and memory problems suicidal thoughts 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 unable to trust difficulty establishing and maintaining close relationships experiences of revictimization trouble setting boundaries drug and alcohol use shoplifting eating disorders self-harm high-risk sexual behaviours suicidal impulses gambling isolation justice system involvement BC Trauma-Informed Practice Guide

24 FACTORS RELATED TO POSTTRAUMATIC STRESS Sequential and long lasting Intentional acts of violence Life threatening events Events causing physical injury In war, the degree of exposure to combat Witnessing death Loss of a loved one due to a traumatic event Unpredictable and uncontrollable events Sexual victimization Briere, 2006

25 DEVELOPMENTAL TRAUMA Starting as infants/children Occurs within caregiving system Affects healthy attachment Changes development shift from learning to surviving

26 TRAUMA EFFECTS IN CHILDREN & YOUTH Affective problems sadness, fear, anxiety or anger, difficulties regulating moods, depressive feelings and increased reactivity or sensitivity Behavioral problems avoidance of trauma reminders (person, place or situation) oppositional behaviors regressive behaviors and problems separating from parents re-experiencing can result in bullying, abusive and /or sexualized behaviors substance use as a way of coping Cognitive problems distorted ideas about why the traumatic event happened and who was responsible shame, worthlessness and loss of trust aligning with and adopting the behaviors of a perpetrator as a way of rationalizing and surviving abusive situations Mannarino, 2006; 2008

27 SOCIAL RESPONSE TO TRAUMA Reduce risk and severity of lasting effects when: There is acceptance (non-blaming, non-stigmatizing) There is caring and nurturing from loved ones There is availability of helpers and support or aid agencies Briere, 2009

28 INTERACTIONS WITH SERVICE PROVIDERS 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, 2012)

29 THE INTERCONNECTIONS OF TRAUMA, MENTAL HEALTH AND SUBSTANCE USE CONCERNS

30 ACE S STUDY Felitti & Anda, 2010

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32 Making the Links Sexual Orientation Disability Poverty Experience of Loss Racial Discrimination Substance Use Problems Age Trauma Violence Mental Ill Health Punishment/ Incarceration Colonization HIV/AIDS Context/ Isolation Resilience Public policy Systemic discrimination Mothering Access to health care Partnership /Friendship

33 How do we prevent FASD? Study of Birth Mothers of children with Fetal Alcohol Syndrome Of the 80 interviewed: 100% seriously sexually, physically or emotionally abused 80% had a major unaddressed mental illness 80% lived with men who did not want them to quit drinking (Astley, Bailey, Talbot, & Clarren, 2000)

34 TRAUMA-INFORMED PRACTICE IN ACTION

35 TIP APPLICATION CONSIDERATIONS Understand the role that violence and trauma play in the lives of most people who access substance use and mental health services Integrate this knowledge into all aspects of service delivery, including supporting survivors to manage their trauma responses successfully so that they are able to access, retain, and benefit from the services This means not only do services and systems accommodate the vulnerabilities of trauma survivors, but they actively facilitate survivors participation in treatment Harris & Fallot, 2001

36 TIP CAN BE SEEN IN A CHANGE IN THE WAY WE VIEW OUR CLIENTS Shift from: What is wrong with her to What happened to her Change in language away from: Controlling Paranoid Manipulative Uncooperative Untreatable Masochistic Attention seeking Drug seeking Bad mother Not believable, etc. (Williams & Paul, 2008)

37 TRAUMA INFORMED INTAKE PRACTICES 2011 FOCUS GROUPS OF BC ADDICTIONS AND MENTAL PROVIDERS TIP can be seen in flexible intake and assessment processes that: Create safety (including cultural safety) Engage establish a therapeutic relationship Do not press for compliance. Screen for present concerns Normalize client experience(s) Set boundaries Identify symptoms

38 EXAMPLES OF TIP APPLICATION IN EARLY INTERACTIONS Clinical and non-clinical staff collaborate to reflect on how to: Provide clear, practical information at initial contacts about what to expect, choices for being contacted and rationale for processes Provide opportunities for questions Respond to people who arrive in distress Guarino et al. 2003; Fallot & Harris, 2009; Gender Matters, 2003

39 ABORIGINAL Recognize diversity (learn about background, history, identity & culture) Provide opportunities for longer engagement process given history of oppressive policies Be prepared to offer clients a larger social context for problems link to colonial history Recognize the value of traditional knowledge and cultural/spiritual practices Partner with cultural helpers/cultural teachers/elders Menzies, 2012

40 APPLICATION OF TIP EXAMPLES: MAKING LINKS Disclosure of trauma is not required Acknowledge common, connections between substance use and trauma Recognize range of responses people can have Recognize that because of trauma responses, developing trusting relationships can be difficult Recognize when someone is triggered or experiencing the effects of trauma & support BC TIP Guide, 2013; Gender Matters,2013

41 POSSIBLE SIGNS OF A TRAUMA RESPONSE Sweating Change in breathing (breathing quickly or holding breath) Muscle stiffness, difficulty relaxing Flood of strong emotions (e.g., anger, sadness, etc.) Rapid heart rate Startle response, flinching Shaking Staring into the distance Disconnected from present conversation, loses focus Unable to concentrate or respond to instructions Unable to speak (Schachter, 2009)

42 EXAMPLES OF TIP APPLICATION PHYSICAL ENVIRONMENT Consider: Signage with welcoming messages and avoid rule based language; with do not messages Making waiting areas comfortable and inviting Lighting in outside spaces Accessibility and safety of washrooms In counseling rooms choice about whether door is open or closed Fallot & Harris, 2009, & Gender Matters, 2013

43 EXAMPLES OF APPLICATION IN DIRECT SERVICE/COUNSELLING Maximize: consistency follow through - if you say you will do something honesty and transparency Consider: avoiding unnecessary disappointment whether people are fully informed of risks during consenting & have choice for partial consent or withholding consent Guarino et al. 2003; Fallot & Harris, 2009; Gender Matters, 2003

44 CHOICE & CONTROL APPLICATIONS Consider the following areas of choice: about when, where and by whom services are provided about priorities and goals that will inform service plan about who attends appointments and meetings, e.g. support people Ask permission to ask a question; or engage in policy based practice, e.g. checking belongings at beginning of residential program Guarino et al. 2003; Fallot & Harris, 2009; Gender Matters, 2003

45 COPING & SKILL BUILDING FOR ALL Indigenous knowledge/cultural approach to healing talk to respected Elders/Teachers about how to cope; stay healthy or access cultural programs Grounding Sensory Cognitive Self-soothing Containment Mindfulness - developing awareness of the present moment; a particular way of paying attention Self-compassion- extending compassion to one s self in instances of perceived inadequacy, failure or general suffering

46 JUDITH HERMAN STAGES OF RECOVERY 1. Safety and stabilization 2. Remembrance and mourning 3. Reconnection and integration Herman, 1992

47 ADDITIONAL CONSIDERATIONS Ask people if there is anything that they have used in the past to support grounding that was either helpful or unhelpful Different strategies work for different people It takes practice to be able to fully benefit from grounding It is most effective to use strategies at the initial stages of uncomfortable moods

48 COMMUNITY BASED RESEARCH Digital Stories First Nations Women Explore the Legacy of Residential Schools: Intergenerational Effects on Professional First Nations Women Whose Mothers are Residential School Survivors From Stilettos to Moccasins: Aboriginal women drug users in conflict with the law: developed a video, song and workshop about their identity and healing journey

49 BLOOM S 7 QUALITIES OF TIP ORGANIZATIONAL CULTURES 1. Culture of non-violence building safety skills and commitment to higher goals 2. Culture of emotional intelligence affect management 3. Culture of inquiry and social learning helping to build cognitive skills 4. Culture of shared governance civic skills of self-control, selfdiscipline and administration of healthy authority 5. Culture of open communication Overcoming barriers to healthy communication 6. Culture of social responsibility Strengthen or rebuild social connection skills 7. Culture of growth and change Maintain/restore, hope, meaning, purpose and empower positive change Bloom, 2005

50 TRAUMA INFORMED SYSTEMS

51 Influencing social conditions creating need for trauma informed practice interagency and inter-sectoral collaboration our service culture our interactions with our clients TRAUMA INFORMED PRACTICE AND POLICY IS RELEVANT AT ALL THESE LEVELS Poole, 2012

52 INTERSECTIONS OF TIP THINK ABOUT RELATED SERVICE AREAS Violence Parenting Substance Use Trauma Mental Health

53 TRAUMA INFORMED SYSTEMS Understand the role that violence and trauma play in the lives of most people who access substance use and mental health services Integrate this knowledge into all aspects of service delivery, including supporting survivors to manage their trauma symptoms successfully so that they are able to access, retain, and benefit from the services This means not only do services and systems accommodate the vulnerabilities of trauma survivors, but they actively facilitate survivors participation in treatment. (Harris & Fallot, 2001)

54 INEQUITIES AND SYSTEMIC DISCRIMINATION Trauma informed systems deliver and promote services that are culturally safe, take into account a socio-historical understanding of client/patient experiences and are informed by an awareness of the existence and impact of social inequities and systemic discrimination BC Trauma-Informed Guide, 2013

55 DISCUSSION What are some of the trauma informed practices you think are currently in place within your community/services? What are some areas where you think TIP could be strengthened? How could sectors/systems work collaboratively towards the development of a trauma informed service system?

56 The following includes a selection of treatment related resources and curricula. Some are focused solely on trauma-informed practices and others incorporate elements of both trauma-informed and trauma-specific approaches. Becoming Trauma-Informed Published by the Centre for Addiction and Mental Health in Ontario, this book offers examples of the ways in which practitioners have applied principles of trauma-informed practice in their work with diverse populations and in diverse settings within the MHSU field. ments/becoming_trauma_informed.pdf Beyond Trauma: A Healing Journey for Women Created by Dr. Stephanie Covington, this trauma treatment manual makes the connection between women s experiences of trauma and their substance use. It can be used in a variety of settings, including residential and outpatient treatment settings, mental health programs, and criminal justice settings. Freedom from Violence: Tools for working with Trauma, Mental Health and Substance Use Developed by the Ending Violence Association of BC, this comprehensive toolkit offers specific, practical trauma-informed strategies for working with women who have substance use and mental health concerns. Strategies for discussing substance use, mental health concerns and for safety planning are included. Handbook on Sensitive Practice for Health Care Practitioner: Lessons from Adult Survivors of Childhood Sexual Abuse Published by the Public Health Agency of Canada, the handbook presents information designed to help health care practitioners practice in a way that is sensitive to the needs of adult survivors of childhood sexual abuse and other types of interpersonal violence. Helping Men Recover: A Program for Treating Addiction This resource, developed by Dr. Stephanie Covington, describes a trauma-informed treatment program for men, making the links between substance use and trauma. There is also a version for women.

57 Seeking Safety Created by Lisa Najavits, Seeking Safety is a widely used curriculum for Stage I trauma support. There are 25 topics that can be presented individually and in any order. The focus is on creating safety and recognizing the connection between substance use and trauma. It has been used in a variety of settings and with both men and women, as well as with youth. Trauma Matters Guidelines developed by the Jean Tweed Centre, in consultation with service providers, experts, and women with lived experience from across Ontario, to support organizations that provide substance use treatment services for women. Designed to aid in understanding the interconnections of trauma and substance use, and provide better care for substanceinvolved women who have experienced trauma. The Trauma Toolkit Developed by Klinic Community Health Centre in Winnipeg, MB, this resource offers general guidelines for trauma-informed practice to assist service providers and agencies to increase their capacity in delivering trauma-informed services. Trauma Recovery and Empowerment Model (TREM) Offered by Community Connections in Washington DC, the TREM curriculum consists of 29 sessions focusing on empowerment, education about trauma, and building coping skills. There are versions for working with women, men, and youth. You are not alone: Violence, Substance Use and Mental Health A peer approach to increasing your safety Created by the Ending Violence Association of BC, this resource is for peer helpers and service providers to assist in discussions about relationship violence and sexual assault among women who may also have MHSU issues.

58 CONTACT INFORMATION Diane Smylie Provincial Trauma Informed Practice Project