Introduction to Trauma Informed Practice

Transcription

1 Introduction to Trauma Informed Practice Nancy Poole January 22, 2014 Saskatoon January 24, 2014 Prince Albert

2 Definitions and History

3 Definitions of trauma Trauma means 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. (Definition used for the Women s Co-occurring Disorders and Violence Study)

4 Definitions of trauma Interpersonal trauma will be 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. (Bierman, Mason et al., 2010)

5 Definitions of trauma In plain language from a CAMH pamphlet: Trauma is the emotional response when an injury overwhelms us. The injury could be physical, sexual, or emotional. (Centre for Addiction and Mental Health, 2000)

6 Trauma and PTSD The terms violence, trauma, abuse, and postttraumatic 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 that results from trauma. (Covington, 2003)

7 Trauma The Concept & History 1940s 1980s Landmark Survey 25% of women raped 33 % sexually abused Coconut Grove Fire early awareness of PTSD in civilians PTSD added to DSM III 1960s Vietnam War PTSD awareness of PTSD in veterans 1992 Herman s book: Trauma & Recovery 1970s Women s movement public to private specialized services 1600s Greek traumatikos (wound) Psychic Wound 1800s Freud lasting & latent effects Early 1900s WW I Shellshock

8 Trauma Contemporary Adverse Childhood Experiences Study (ACE s) prevalence of adverse childhood experiences linkages with physical/mental health & substance use Recognition of trauma caused by colonization & indigenous specific racism Historical trauma (Indian Residential Schools, Indian Hospitals, 60 s scoop) Intergenerational trauma Efforts to redress trauma related to residential schools Feminists working on prevention of violence against women bring attention to the intersections of violence, trauma, mental health, substance use & social determinants of health Neurobiological approaches to healing from trauma (drawing on mindfulness techniques and attachment theory) are developed.

9 The effects of trauma

10 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)

11 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 Loss of meaning Loss of connection to self, family, culture, community, nature, a higher power feelings of shame, guilt self-blame feel completely different from others 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

12 Trauma effects (2) Affective presentations Sadness, fear, anxiety, anger, reactivity, sensitivity Behavioral presentations Avoidance, regression, bullying, abusive and/or sexualized behaviour Cognitive presentations Self blame, blaming other victims, loss of trust. Adopt behaviours of perpetrator as way to rationalize Cohen & Mannarino

13 Trauma effects (3) Trauma effects can also be organized by the PTSD symptom clusters as identified in the DSM V Intrusion/re-experiencing e.g. memories, nightmares, flashbacks, intense emotional or psychological response to reminders of event Avoidance e.g. people, conversations, situations, places, objects and feelings, thoughts and bodily sensations Arousal/reactivity e.g. irritability, hyper vigilance (always on guard), difficulties with concentration and sleep Negative mood/cognitions, which may include, feeling detached, inability to experience emotions (numbing) and depressive symptoms, for instance, loss of hope, interest, persistent guilt, anger and/or fear

14 Long term effects Long term effects include: Feelings of powerlessness Dissociation and changes in consciousness Difficulty with relationships, trust Somatization Self blame and poor self-image Vulnerability to further abuse (Haskell, 2003)

15 ACE s Study conception Mechanisms by which Adverse Childhood Experiences influence Health and Well-being throughout the lifespan Felitti & Anda, 2010

16 Physical effects Experiences of violence/trauma are linked to central nervous system changes, sleep disorders, cardio vascular problems, gastrointestinal and genito-urinary problems, reproductive and sexual problems Chronic danger and anticipation of violence can stress the immune system which can lead to an increased susceptibility to autoimmune disorders (chronic fatigue, fibromyalgia) and other illnesses

17 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

18 The interconnections of trauma, mental health and substance use concerns

19 Trauma is common 76% of Canadian adults report some form of trauma exposure in their lifetime 9.2% meet the criteria for PTSD An estimated 50% of all Canadian women and 33% of Canadian men have survived at least one incidence of sexual or physical violence Experience of trauma is particularly common among those who have mental health and substance use problems

20 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) How do we prevent FASD?

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

22 Trauma affects service access & 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

23 Trauma informed practice: Key principles

24 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

25 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 traumainformed care

26 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 4 Key Principles 2. Emphasis on safety and trustworthiness Ensuring informed consent Creating crisis plans

27 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)

28 Trauma-informed services create safe environments that foster a client s sense of efficacy, self-determination, dignity, and personal control. 4 Key Principles 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 3.Opportunity for choice, collaboration and connection

29 Service providers: Help clients identify their strengths Further develop resiliency and coping skills 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

30 Trauma-Informed Practice in Action

31 Influencing social conditions creating need for trauma informed practice interagency and intersectoral collaboration our service culture our interaction s with our clients Trauma informed practice and policy is relevant at all these levels

32 Intervention is not a specialist problem but a broad social responsibility that should be shared by many public and private sectors Carroll & Miller, 2006 Rethinking substance abuse: what the science shows, and what we should do about it.

33 TIP can be seen how we view clients who experience difficulty accessing services Shift from: What is wrong with her to What happened to her Change in language away from: Controlling Manipulative Uncooperative Untreatable Masochistic Attention seeking Drug seeking Bad mother Not believable, etc. (Williams & Paul, 2008)

34 Reframing language From Controlling Manipulative Attention seeking Symptoms Borderline Malingering To The individual seems to be trying to assert their power The individual has difficulty asking for what they want The individual is trying to connect the best they can Adaptations The individual is doing their best given their early experiences The individual is seeking help in a way that feels safer

35 TIP Application: Trauma awareness 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 Disclosure of trauma is not required Recognize when someone is triggered or experiencing the effects of trauma & support BC TIP Guide, 2013 Gender Matters, 2013

36 TIP can be seen in flexible intake practices Trauma informed intake practices - 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 2011 focus groups of BC addictions and mental providers

37 TIP 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 Trauma-informed Organizational Assessment for programs serving families experiencing homelessness, 2003 Creating Cultures of Trauma-informed Care 2009 Trauma Matters, 2013

38 TIP application: 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 counseling rooms choice about whether door is open or closed Fallot & Harris, 2009, & Ontario Guidelines, 2013

39 TIP Supporting skill development - Grounding When people are feeling unsafe or overwhelmed by painful memories or emotions it is often helpful to use grounding techniques to help regain control over feelings and reconnect with the present. These skills can be practiced and strengthened over time and become anchors that can help to manage cravings, feelings of numbness, states of hyperarousal and difficult memories or flashbacks. Haskell, 2003

40 TIP in counselling practice Understanding of multiple & complex links between trauma & addiction Understanding trauma related symptoms as attempts to cope Service users will not have to disclose a trauma history to receive trauma-sensitive services. All services will be trauma sensitive All staff will be knowledgeable about impact of violence & trained to behave in ways that are not re-traumatizing Service users will have access to trauma specific services (Harris & Fallot, 2001)

41 Trauma informed practice within treatment for Indigenous women Collaborative research project (2005) led by Dr. Colleen Dell, between the National Native Addictions Partnership Foundation, the Canadian Centre on Substance Abuse and the University of Saskatchewan.

42 Empathy Relay empathy for the struggles that women face due to their problematic substance use (for example, loss of custody of their children). Acceptance / Having a nonjudgmental attitude Be accepting and non-judgemental about women s past behaviours (for example, women s involvement in prostitution for survival). Inspiration Provide inspiration by acting as a role model (for example, when appropriate share parts of your own healing journey to show it is possible to gain further education as an adult and secure meaningful employment). RE-CLAIM Recognition Communication Care Link to spirituality Momentum Recognize the impact of trauma in women s healing (ranging from the intergenerational effects of colonialism through to the disproportionate rates of inter-personal violence faced by Aboriginal women). Open lines of communication for two-way, non-hierarchical dialogue with the women. Show care for the women and passion for your own role as a treatment provider. Support the link to spirituality in women s healing through Aboriginal culture as well as any other traditions and teachings with which the women identify. Promote momentum in the women s healing journeys; that is, assist the women in moving toward the future after acknowledging the past (promoting accountability). For example, assist the women in developing healthier relationships and parenting skills. Fostering the women s ties to their communities will help break generational cycles. Participatory research project (Stilettos to Moccasins) led by Dr. Colleen Dell, See ionresearchchair. ca/

43 TIP as prevention of seclusion and restraint

44 TIP with child welfare populations Transition age youth need a distinct culture of care - Patrick McGorry Families living in urban poverty Trauma Adapted Family Connections (TA-FC) Collins, et al. (2011). Trauma adapted family connections: Reducing developmental and complex trauma symptomatology to prevent child abuse and neglect. Phase 1 Phase 2 Phase 3 Engagement Assessment Helping families meet their basic needs Safety Planning Family psycho-education Emotional regulation Strengthening family relationships Family shared meaning of trauma Closure and endings Reflection Transparency C o l l a b o r a t i o n

45 TIP can look like avoidance of retraumatization through joined up services Women impacted by violence/trauma, mental health issues and substance use Are at greater risk of barriers to housing Are at risk of losing contact with children Poverty is a barrier to accessing services Isolated... (Cory et al., 2010)

46 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)

47 TIP at the Organizational Level Prevention of Vicarious Trauma

48 Bloom s 7 Qualities of TIP Organizational Culture 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 democracy civic skills of self-control, self-discipline and administration of healthy authority Bloom, 2005

49 7 Qualities of TIP Organizational Culture 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

50 Healthy Organizations are emotionally well regulated Organizational TIP is an approach to a whole culture that increases the emotional IQ of everyone and the organization as a whole A healthy organization is able to contain and manage the difficult and distressful emotions of the people who comprise the organization. Fear, anger, anxiety, grief, shame and frustration are unavoidable feelings in all of our work lives Bloom, 2013

51 TIP Organizational Checklist 1. Overall Policy and Program Mandate 2. Administration 3. Hiring Practices 4. Training for Staff 5. Support and Supervision of Staff 6. Assessment and Intake 7. Policies and Procedures 8. Monitoring and Evaluation

52 Vicarious Traumatization (Trauma Exposure Response) refers to the cumulative transformative effect on the helper working with the survivors of traumatic life events The impact of vicarious trauma occurs on a continuum, influenced by factors such as: role amount of exposure to traumatic information degree of support in the workplace personal life support personal experiences of trauma Saakvitne and Pearlman, 1996 BC TIP Guide, 2013

53 Practitioner Wellness Attend to mental and physical health through: Active & ongoing self-care strategies Engagement with colleagues Adequate time to de-stress Attention to personal needs Courtois & Ford, 2013

54 Protective Practices Countering isolation Develop mindful awareness Embracing complexity Empathic engagement Active optimism Holistic self-care Professional satisfaction Honoring limits Creating meaning Harrison, R.L. and M.J. Westwood, 2009

55 ABC Model promoting wellness Awareness attunement to one s needs, limits, emotions and resources Balance balancing the multiple aspects of self & one s activities Connection to oneself, to others and to something larger Saakvitne, K.W. and L. Pearlman, 1996

56 Trauma informed practice: A system-wide quality improvement strategy

57 Becoming trauma informed Becoming trauma informed requires a range of adjustments in practice and system designs, supported by research, innovative change and inspired leadership. This is a tall order, and requires complex thinking. Becoming trauma informed benefits from collaboration and cooperation between all levels of service delivery. Becoming trauma informed is an ongoing process of system change and quality improvement, requiring constant adaptations and ongoing monitoring.

58 There are many reasons to be hopeful Strong interest by practitioners - e.g. online web workspace, and CoPs Great contributions by survivors e.g. Grounding Trauma conferences Interest at the level of systems improvement for example in mental health and substance use plans, in collaborations between substance use and child welfare systems

59 Nancy Poole

60 References Astley, S. J., Bailey, D., Talbot, C., & Clarren, S. K. (2000). Fetal Alcohol Syndrome (FAS) Primary Prevention through FASD Diagnosis II: A comprehensive profile of 80 birth mothers of children with FAS. Alcohol and Alcoholism, 35(5), Azeem, M.W., Aujla, A., Rammerth, M., Binsfeld, G., Jones, R.B. (2011). Effectiveness of Six Core Strategies Based on Trauma Informed Care in Reducing Seclusions and Restraints at a Child and Adolescent Psychiatric Hospital. Journal of Child and Adolescent Psychiatric Nursing, 24, Bloom, S. L., & Farragher, B. (2013). Restoring Sanctuary: A new operating system for trauma-informed systems of care New York, NY: Oxford University Press Brave Heart, M. Y. H. (1998). The return to the sacred path: Healing the historical trauma response among the Lakota. Smoth College Studies in Social Work, 68(3), Briere, J. A. S. (2006). Principles of trauma therapy: A guide to symptoms, evaluation, and treatment. Thousand Oaks: Sage Publications. CAMH. (2000). Common questions about trauma. Retrieved from CAMH. (May 2008). Restraint Minimalization Taskforce Final Report. Toronto, ON: Centre for Addiction and Mental Health. Carroll, K.M. & Miller, W.R, eds. (2006) Rethinking substance abuse: what the science shows, and what we should do about it. Guilford Press, New York Chansonneuve, D. (2007). Reclaiming Connections: Understanding Residential School Trauma among Aboriginal People. Ottawa, ON: Aboriginal Healing Foundation Cohen, J. A., & Mannarino, A. P. (2008). Trauma-focused cognitive behavioural therapy for children and parents. Child and Adolescent Mental Health, 13(4), doi: /j x Collins, K. S., Strieder, F. H., DePanfilis, D., Tabor, M., Clarkson-Freeman, P. A., Linde, L., & Greenberg, P. (2011). Trauma Adapted Family Connections: Reducing Developmental and Complex Trauma Symptomatology to Prevent Child Abuse and Neglect. [Article]. Child Welfare, 90(6), Cory, J., & Dechief, L. (2007). Safety and Health Enhancement (SHE) for Women Experiencing Abuse: A framework for health care providers and planners Vancouver, BC: BC Women's Hospital, Woman Abuse Program. Courtois, C. A., & Ford, J. (2013). The Treatment of Complex Trauma: A Sequenced Relationship-Based Approach. New York: Guildford Press Covington, S.S. (2003). Beyond Trauma: A Healing Journey for Women. Center City, MN: Hazeldon.

61 References (Part 2) Clark, H. W., & Power, A. K. (2005). Women, co-occurring disorders, and violence study: A case for trauma-informed care. Journal of Substance Abuse Treatment, 28(2), Felitti, V., Anda, R., Nordenberg, D., Williamson, D., Spitz, A., Edwards, V.,... Marks, J. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the adverse childhood experiences (ACE) study. American Journal of Preventive Medicine, 14, Fallot, R., & Harris, M. (2009). Creating cultures of trauma-informed care (CCTIC): A self-assessment and planning protocol. 2.2(7), Retrieved from Harris, M., & Fallot, R., D. (2001). Using Trauma Theory to Design Service Systems. San Francisco, CA: Jossey Bass Harrison, R. L., & Westwood, M. J. (2009). Preventing vicarious traumatization of mental health therapists: Identifying protective practices. Psychotherapy: Theory, Research, Practice, Training, 46(2), Haskell, L. (2003). First Stage Trauma Treatment: A guide for mental health professionals working with women. Toronto, ON: Centre for Addiction and Mental Health. Jean Tweed Centre. (March 2013). Trauma Matters: Guidelines for Trauma-Informed Services in Women's Substance Use Services Toronto, ON. Markoff, L. S., Reed, B. G., Fallot, R. D., Elliott, D. E., & Bjelajac, P. (2005). Implementing trauma-informed alcohol and other drug and mental health services for women: Lessons learned in a multisite demonstration project. American Journal of Orthopsychiatry, 75(4), Najavits, L. M. (2002). Seeking Safety: A Treatment Manual for PSTD and Substance Abuse. New York, NY: Guilford Press. Poole,N. (2008). Interconnections among Women s Health, Violence and Substance Use. In Greaves, L., & Poole, N. (Ed.) (2008). Highs & Lows: Canadian Perspective on Women and Substance Use. Toronto, ON: Centre for Addiction and Mental Health Poole, N., & Greaves, L. (Eds.). (2012). Becoming Trauma Informed. Toronto, ON: Centre for Addiction and Mental Health Poole, N., Urquhart, C., Jasiura, F., Smylie, D., & Schmidt, R. (May 2013). Trauma Informed Practice Guide Victoria, BC: British Columbia Centre of Excellence for Women's Health and Ministry of Health, Government of British Columbia. Prescott, L., Soares, P., Konnath, K., & Bassuk, E. (2008). A Long Journey Home: A guide for generating trauma-informed services for mothers and children experiencing homelessness. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration; and the Daniels Fund; National Child Traumatic Stress Network; and the W.K. Kellogg Foundation. Saakvitne, K. W., & Pearlman, L. (1996). Transforming the pain: A workbook for vicarious traumatization. New York: Norton. Schachter, C., Stalker, C. A., Teram, E., Lasiuk, G. C., & Danilkewich, A. (2008). Handbook on Sensitive Practice for Health Care Practitioners: Lessons from Adult Survivors of Childhood Sexual Abuse. Ottawa, ON: National Clearinghouse on Family Violence. Van Ameringen, M., Mancini, C., Patterson, B., Boyle, M.H. (2008). Post-Traumatic Stress Disorder in Canada. CNS Neuroscience & Therapeutics, 14(3), Williams, J., Paul, J. (2008). Informed Gender Practice: Mental health acute care that works for women. National Institute for Mental Health, UK.