System of Care. (Sheila A. Pires, 2002)

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2 Outline : Definitions Prevalence and Effects of Trauma Why Become Trauma Informed? What does it mean to be Trauma Informed? Core Principles of Trauma Informed System of Care Creating a Trauma Informed System of Care

3 Trauma Event that includes physical, psychological, and sexual abuse; terrorism and war; domestic violence; witnessing violence against others; accidents and natural disasters (Facts about trauma, 2013). Emotional reactions to the traumatic event (fear, horror, helplessness) are no longer part of the criteria as a variety of other symptoms may predominate (DSM 5, 2013). 3

4 System of Care A system of care incorporates a broad array of services and supports that is organized into a coordinated network, integrates care planning and management across multiple levels, is culturally and linguistically competent, and builds meaningful partnerships with families and youth at service delivery and policy levels. (Sheila A. Pires, 2002)

5 Traumatic Event Vs. Traumatization An intense event, more overwhelming than a person would normally expect to occur, where a person feels they have no power or control over the situation. When a traumatic event causes lingering and pervasive emotional, behavioral, physical and developmental effects.

6 Prevalence of Trauma Among year old youth, 8% reported a lifetime prevalence of sexual assault, 17% reported physical assault, and 39% reported witnessing violence (Kilpatrick & Saunders, 1997). Female college students have the greatest risk for sexual and interpersonal violence (Smyth et al., 2008; Vrana & Lauterbach, 1994). 90% of public mental health clients have been exposed to multiple experiences of trauma (Goodman, Rosenburg et al., 1997; Mueser et al., 1998). Teenagers with alcohol and drug problems were 6 to 12 times more likely to have a history of being physically abused and 18 to 21 times more likely to have been sexually abused than those without alcohol and drug problems (Clark et al., 1997). 97% of homeless women with mental illness experienced severe physical and/or sexual abuse, 87% experienced this type of abuse both as children and as adults (Goodman, Dutton et al., 1997). 6

7 Prevalence of Trauma The majority of adults and children in psychiatric treatment settings have trauma histories. A sizable percentage of people with substance use disorders have traumatic stress symptoms that interfere with achieving or maintaining sobriety. A sizable percentage of adults and children in the prison or juvenile justice system have trauma histories (Hodas, 2004, Cusacket al., Mueseret al., 1998, Lipschitzet al., 1999, NASMHPD, 1998)

8 Traumatized Children: Appear guarded and anxious; Are difficult to re-direct, reject support; Are highly emotionally reactive; Have difficulty settling after outbursts; Hold onto grievances; Do not take responsibility for behavior; Make the same mistakes over and over; World is threatening and bewildering World is punitive, judgmental, humiliating and blaming; Control is external, not internalized; People are unpredictable and untrustworthy; Defend themselves above all else; and Believe that admitting mistakes is worse than telling truth. (Hodas, 2004)

9 Effects of Trauma By adolescence, children have sufficient skill and independence to seek relief through the following: Drinking alcohol Smoking tobacco Sexual promiscuity Using psychoactive materials Overeating/eating disorders Delinquent behavior 9

10 Impact of Trauma Over the Lifespan Neurological, biological, psychological and social in nature. They include: Changes in brain neurobiology Social, emotional and cognitive impairment Adoption of health risk behaviors as coping mechanisms (eating disorders, smoking, substance abuse, self harm, sexual promiscuity, violence) Severe and persistent behavioral health, health and social problems, early death (Felitti et al., 1998). 10

11 The Adverse Childhood Experiences (ACE) Study Provides retrospective and prospective analysis in over 17,000 individuals on the effect of traumatic experiences during the first 18 years of life on adolescent and adult medical and psychiatric disease, sexual behavior, healthcare costs, and life expectancy (Felitti et al., 1998). 11

12 Abuse Emotional Physical Contact Sexual Abuse ACE Categories 12

13 Household Dysfunction ACE Categories Mother treated violently Household member was alcoholic or drug user Household member was imprisoned Household member was chronically depressed, suicidal, mentally ill, or in a psychiatric hospital Not raised by both biological parents 13

14 ACE Categories Neglect Physical Emotional 14

15 ACE STUDY FINDINGS ACE score increased the chances of being a user of street drugs, tobacco, having problems with alcohol, overeating, sexual behaviors. Individuals with an ACE score of 4 or more were twice as likely to be smokers, 12 times more likely to have attempted suicide, 7 times more likely to be alcoholic, and 10 times more likely to have injected street drugs compared to those with an ACE score of 0. 15

16 ACE STUDY FINDINGS ACE scores were related to increased heart disease, cancer, chronic bronchitis or emphysema, history of hepatitis, and poor self-rated health. 16

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18 WHAT ABOUT THERAPISTS WORKING WITH TRAUMA? 6% to 26% of therapists working with traumatized populations, and about 50% of child welfare workers are at risk for secondary traumatic stress or related conditions of PTSD and vicarious trauma. Secondary traumatic stress - compassion fatigue the presence of at least one indirect exposure to traumatic material. Compassion fatigue - symptoms and conditions may include hopelessness, inability to listen, avoidance of clients, anger and cynicism, sleeplessness, fear, chronic exhaustion, and minimizing. A traumatized organization is less likely to effectively identify its clients past trauma or prevent future trauma. (National Child Traumatic Stress Network, 2011) 18

19 Why a Trauma Informed System? 19

20 Research Shows Even in academic and community mental health settings, rates of recognition of trauma are low with a clinical diagnosis of PTSD occurring in as few as 4% of individuals with the disorder (Davidson, 2001; Sher et al., 2004). A parallel may be drawn between the lack of awareness a decade ago of substance use disorders in patients with SMI, whereas in recent years there has been growth of assessment of these disorders and recognition of their negative effects on the course of SMI (Drake et al., 1996). Understanding the role of trauma and PTSD in influencing the course of SMI may lead to similar changes with assessment of trauma becoming routine and accepted as a necessary standard of practice (Mueser et al., 2002).

21 Research Shows Failure to diagnosis PTSD as a co-morbid disorder in severely mentally ill patients has important implications for assessment and management of their illnesses: Increases patient s vulnerability to substance abuse disorders (Stewart, 1996). Leads to a worse course of serious mental illness (Drake, 1996). Contributes to social isolation and loss of social support, increasing vulnerability to relapse in persons with serious mental illness (Cresswel et al., 1992).

22 Research Shows Many users of mental health services are upset at not being asked about abuse (Lothioan & Read, 2002). Inhibiting or holding back one s thoughts, feelings and behaviors is associated with long-term stress and disease. Failure to confront traumatic experiences forces a person to live with it in an unresolved manner (Pennebaker et al, 1988). Not to inquire may further re-victimize the client (Doob, 1992).

23 Consumer Research Detailed Survey interviews of men and women with histories of psychiatric hospitalization consumers reported finding inquiry helpful. Some said they wanted to further address trauma issues in their treatment (Cuzack et al., 2003). The notion that screening for trauma is helpful for subjects is consistent with other studies conducted with public mental health consumers.

24 Why Don t We Recognize Trauma?

25 Why Don t We Recognize Trauma? Two factors contribute to the fact that significant trauma concerns are frequently overlooked in professional settings: 1. Under-reporting of trauma by survivors 2. Under-recognition of trauma by providers (Cusack 2004; Harris & Fallot, 2001)

26 Trauma Informed System Acknowledges and understands the effects of trauma and values client participation. Takes into account knowledge about trauma, its impact, interpersonal dynamic, and paths to recovery and incorporates this knowledge into all aspects of service delivery. Has an understanding of the profound neurological, biological, psychological and social effects of trauma and violence on the individual. Presumes that every person in a treatment setting has been exposed to abuse, violence, neglect or other traumatic experiences. 26

27 Key Features Systems without Trauma Sensitivity Clients are labeled & pathologized as manipulative, needy, attention-seeking. Misuse or overuse of displays of power - keys, security, demeanor. Culture of secrecy - no advocates, poor monitoring of staff. Staff believe key role are as rule enforcers Little use of least restrictive alternatives other than medication Institutions that emphasize compliance rather than collaboration. Trauma Informed Care Systems Are inclusive of the survivor's perspective. Recognition that coercive interventions that cause traumatization/re-traumatization are to be avoided. Recognition of the high rates of PTSD and other psychiatric disorders related to trauma exposure in children and adults with mental illness. Early and thoughtful diagnostic evaluation with focused consideration of trauma in people with complicated, treatment-resistant illness. Recognition that mental health treatment environments are often traumatizing, both overtly and covertly. Recognition that the majority of mental health staff are uninformed about trauma, do not recognize it and do not treat it. 27

28 Key Features Systems without Trauma Sensitivity Institutions that disempower and devalue staff who then pass on that disrespect to service recipients. High rates of staff and recipient assault and injury. Lower treatment adherence. High rates of adult, child/family complaints. High rates of staff turnover and low morale. Longer lengths of stay/increase in recidivism. Trauma Informed Care Systems Value clients in all aspects of care. Neutral, objective and supportive language. Individually flexible plan approaches. Avoid all shaming/humiliation. Awareness/training on re-traumatizing practices. Institutions that are open to outside parties: advocacy and clinical consultants. Training and supervision in assessment and treatment of people with trauma histories. Focusing on what happened to you in place of what is wrong with you. Asking questions about current abuse. Addressing the current risk and developing a safety plan for discharge/termination. 28

29 The Core Principles of a Trauma-Informed System of Care Safety: Ensuring physical and emotional safety Trustworthiness: Maximizing trustworthiness, making tasks clear, and maintaining appropriate boundaries. Choice: Prioritizing client choice and control. Collaboration: Maximizing collaboration and sharing power with clients. Empowerment: Prioritizing client empowerment and skill-building. (Fallot & Harris, 2009) 29

30 Safety: Physical and Emotional Safety To what extent do service delivery practices and settings ensure the physical and emotional safety of consumers? of staff members? How can services and settings be modified to ensure this safety more effectively and consistently? Do staff feel supported in their relationships with supervisors? Do staff feel comfortable bringing their concerns to a staff meeting?

31 Trustworthiness: Clarity, Consistency, and Boundaries To what extent do current service delivery practices make the tasks involved in service delivery clear? Ensure consistency in practice? Maintain boundaries, especially interpersonal ones, appropriate for the program? How can services be modified to ensure that tasks and boundaries are established and maintained clearly, consistently, and appropriately? Do supervisors have an understanding of burnout, vicarious trauma, compassion fatigue? Is self care encouraged? Does staff feel listened to by supervisors even if they do not agree. 31

32 Choice: Choice and Control To what extent do current service delivery practices prioritize consumer experiences of choice and control? How can services be modified to ensure that consumer experiences of choice and control are maximized? Do staff have choices in how they meet job requirements? Do staff give input opportunities for training, approach to clinical care, caseload size? 32

33 Collaboration: Collaborating and Sharing Power To what extent do current service delivery practices maximize collaboration and the sharing of power between providers and consumers? How can services be modified to ensure that collaboration and power-sharing are maximized? Are staff encouraged to provide feedback and ideas? Do supervisors communicate that staff opinions are valued even if they cannot be implemented? 33

34 Empowerment: Recognizing Strengths and Building Skills To what extent do current service delivery practices prioritize consumer empowerment, recognizing strengths and building skills? How can services be modified to ensure that experiences of empowerment and the development or enhancement of consumer skills are maximized? Are staff offered development/training opportunities. Do staff receive opportunities to advance career goals? Is supervisory feedback constructive? 34

35 Creating a Trauma Informed System of Care

36 When a human service program takes the steps to become trauma-informed, every part of the organization, management, and services delivery system is assessed and potentially modified to include a basic understanding of how trauma impacts the life of an individual receiving services. 36

37 A Culture Shift: Scope of Change in a Distressed System Involves all aspects of program activities, setting, and atmosphere (more than implementing new services). Involves all groups: administrators, supervisors, line staff, consumers, families (more than direct service providers). Involves making change into a new routine, a new way of thinking and acting (more than new information). 37

38 Trauma-Informed Care (TIC) provides a new paradigm under which the basic premise for organizing services is transformed. From: To: What is wrong with you? What happened to you? From: To: Control Collaboration

39 Trauma Informed Systems Universal Precautions: Operate as if every child in our care has been exposed to abuse, violence, neglect, or other traumatic event(s). What happened to you?

40 Protocol for Developing a Trauma- Informed Service System Services-level changes Service procedures and settings Formal service policies Trauma screening, assessment, and service planning Systems-level/administrative changes Administrative support for program-wide traumainformed services Trauma training and education Human resources practices 40

41 Review of Formal Policies Confidentiality policies are clear and shared with clients. Policies avoid involuntary or coercive elements of treatment. De-escalation policy is formalized and minimizes possibility of re-traumatization. Program prioritizes client preferences in responding to crises (e.g., use of preference forms). Program has clearly written, accessible statement regarding client rights and grievances. 41

42 Trauma Screening, Assessment, and Service Planning Universal trauma screening that is appropriate to the setting. Follow-up with appropriate assessment of trauma exposure history and impact. Including trauma-based information in collaborative planning for services. Offering, or linking to, trauma-specific services. 42

43 Screening Questions Trauma screening is usually limited to several questions Range of events may include natural disasters, serious accidents, deaths, physical and sexual abuse Is clear and explicit, particularly about physical and sexual abuse Physical abuse: ask if person has ever been beaten, kicked, punched, or choked Sexual abuse: ask about experiences of being touched sexually against their will, or whether anyone has ever forced them to have sex when they did not want to (Harris & Fallot, 2001).

44 Trauma Informed Assessments An in-depth exploration of: the nature and severity of traumatic events The consequences of those events Current trauma-related symptoms In the context of a comprehensive mental health assessment, the trauma information may contribute to a formal diagnostic decision. 44

45 Administrative Support for Program- Wide Trauma-Informed Services Support for the integration of knowledge about trauma and violence into all aspects of agency functioning. Possible indicators: Formal policy or mission statements Developing a trauma initiative Making resources available Active administrator participation 45

46 Expected Outcomes Program: Improvement in trauma self-assessment Increased provision of trauma-specific services Decrease in client management problems Client: Increased program retention Lower relapse rates Decrease in self-harming behaviors Staff: Increased trauma education Lower turnover Increased job satisfaction 46

47 Conclusion What we know about trauma, its impact, and the process of recovery calls for trauma-informed service approaches. A trauma-informed approach involves fundamental shifts in thinking and practice at all program levels. Trauma-informed services offer the possibility of enhanced collaboration for all participants in the human service system. 47