J. Kellie Evans, LCSW, CSOTP The Up Center Vice President of Child Welfare Services May 15, 2014

Transcription

1 J. Kellie Evans, LCSW, CSOTP The Up Center Vice President of Child Welfare Services May 15, 2014

2 Brief overview of trauma Objectives Learn what a trauma informed approach is and how this approach differs from others Learn the importance of using a trauma informed approach with children involved in the child welfare system and it s implications Learn about trauma informed/focused interventions Learn about vicarious trauma

3 TRAUMA What does that really mean? A traumatic event can involve interpersonal events such as physical, emotional or sexual abuse, war, community violence, neglect, maltreatment, loss of a caregiver/loved one, natural disasters, terrorism, witnessing violence or experiencing trauma vicariously; it can also result from chronic adversity; chronic, severe or life threatening injuries, illness and accidents. Trauma interferes with one s ability to cope.

4 Types of Trauma Complex trauma- Describes the problem of children s exposure to multiple or prolonged traumatic events and the impact of this exposure on their development. Typically, complex trauma exposure involves the simultaneous or sequential occurrence of child maltreatment including psychological maltreatment, neglect, physical and sexual abuse, and domestic violence that is chronic, begins in early childhood, and occurs within the primary caregiving system. Exposure to these initial traumatic experiences and the resulting emotional dysregulation and the loss of safety, direction, and the ability to detect or respond to danger cues often sets off a chain of events leading to subsequent or repeated trauma exposure in adolescence and adulthood. (

5 Types of Trauma Vicarious trauma is the process of change that happens because you care about other people who have been hurt, and feel committed or responsible to help them. Over time this process can lead to changes in your psychological, physical, and spiritual well-being. ( Also referred to as compassion fatigue. Childhood traumatic grief may occur following a death of someone important to the child. The death may have been sudden and unexpected (e.g., through violence or an accident), or anticipated (e.g., resulting from illness or other natural causes). The distinguishing feature of childhood traumatic grief is that the trauma symptoms interfere with the child's ability to go through the typical process of bereavement. The child experiences a combination of trauma and grief symptoms so severe that any thoughts or reminders even happy ones about the person who died can lead to frightening thoughts, images, and/or memories of how the person died. (

6 Types of Trauma Other types which tend to be more common, physical abuse, sexual abuse, emotional abuse, neglect, chronic maltreatment, bullying, exposure to domestic violence, war, terrorism, community violence, medical trauma, school violence and natural disasters.

7 Some trauma findings In 2011, child protective services in the United States received 3.4 million referrals, representing 6.2 million children. Of those cases referred, about 19% were officially founded and occurred in the following frequencies: Keep in mind, all types of abuse are under reported. more than 75 percent (78.5%) suffered neglect more than 15 percent (17.6%) suffered physical abuse less than 10 percent (9.1%) suffered sexual abuse n_and_adolescents_overview_for_professionals.asp

8 More trauma findings 3.9 million adolescents have been victims of serious physical assault, almost 9 million have witnessed an act of serious violence. (Kilpatrick et al, 2001) Childhood trauma is believed to have long term impact in the frontal, temporal and parietal regions of the brain and how information is processed. (Cook et al., 2009) Childhood trauma, compared to adult-onset trauma results in a greater probability of developing psychiatric disorders (particularly anxiety disorders and PTSD) throughout the lifetime. (Zlotnick et al., 2008)

9 Some Child Welfare findings Approximately 27, 000 children age out of the foster care system annually Nearly 40% experience homelessness- 3 out 10 homeless adults reported being in foster care in Nearly 60% of young males are convicted of crime Only 48% are employed 75% of females and 33% of males receive government assistance 50% of those who age out have been involved in substance abuse. 17 % of female foster children under 18 are pregnant Nearly 25% of those who age out do not have a GED or HS diploma 70% show a desire to attend college, only 6% graduate. On average, 63% of former foster children earn minimum wage

10 Impact of trauma on children Attachment problems-trouble with relationships, boundaries, empathy and social isolation Physical health-impaired, sensorimotor development, coordination problems, somatic symptoms, medical problems Emotional- Poor emotional regulation, difficulty identifying and labeling feelings and communicating needs Dissociation-Altered states of consciousness, amnesia and impaired memory Cognitive ability-problems with focus, memory, processing new information, language development, orientation to time and space Self-concept-lack of consistent sense of self, poor body image, low selfesteem, shame and guilt Behavioral control-poor impulse control, defiant/oppositional, aggression, disrupted sleep and eating patterns, trauma re-enactment

11 Definition of Trauma Informed Care Trauma-informed care is an approach to engaging people with histories of trauma that recognizes the presence of trauma symptoms and acknowledges the role that trauma has played in their lives. -National Center for Trauma Informed Care (NCTIC, )

12 Trauma Informed Care Approach became forefront as a response to trauma research and brain research about the effects of trauma on the brain. Initially became aware of it s impact after the Vietnam War ACE (Adverse Childhood Experience) study heightened our awareness of the prevalence and impact of childhood trauma on adult health and wellbeing. It put the impact in $$$ terms-people have listened. ( )

13 What does it mean for an organization to be trauma informed? When a human service organization takes the step to become trauma-informed, every part of its organization, management, and service delivery system is assessed and potentially modified to include a basic understanding of how trauma affects the life of an individual seeking services. 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. -NCTIC,

14 How does an agency become TI? This process is a transformation and no easy feat. It involves top to bottom personnel and processesagency/program leadership, middle management, direct service staff, administrative and operational staff-from the big boss to the janitor. AND the clients being served!!!! Training of all hands is critical. Review of all policies and procedures. Are they trauma informed practices?

15 Key Principles of the TIC approach Safety- environment promotes a sense of safety both physically and psychologically Trustworthiness and transparency- operations and decisions are clear and not secretive with the goal of building and maintaining trust among staff, clients and family members of people served. Collaboration and mutuality- true partnering and leveling of power differences between staff and people served and between operations to direct care staff to management. Empowerment-model is applied across personnel and people served Voice and choice-individualized approach to serving people and strengthens choice

16 Key Principles of the TIC approach, cont. Peer support and mutual self-help- key to organizational functioning and service delivery Resilience and strengths based- belief in resilience and the ability of the collective us to heal and promote recovery by building on client strengths not weaknesses. Inclusiveness and shared purpose-recognizing that EVERYONE has a role to play in a TIC approach. you don t have to be a therapist to be therapeutic (Gillece, 2013)

17 Trauma Informed Child Welfare Activities Maximize safety. Use a comprehensive assessment of the child s traumatic experiences and it s impact on the child to guide service delivery Connect child, parents, caregivers with trauma focused treatment Intensive service coordination Support and promote positive and stable relationships in the child s life Look at creative ways to support caregivers of the child Manage professional and personal stress

18 Engaging and supporting families in the child welfare system Trauma in adult caregivers impacts their ability to make appropriate judgments about safety Trauma makes it hard to form and sustain secure, lasting relationships Trauma impacts the ability to regulate emotions Trauma leads to poor self-esteem and maladaptive coping strategies Vulnerability to trauma triggers and other life stressors is high Trauma impairs ability to make decisions about the future

19 Things you won t see at a TIC agency STAFF only bathrooms NO CLIENTS ALLOWED DO NOT signs-don t touch the glass, Don t sit children on the counter, No loitering, No food and drink allowed..no, NO, NO everywhere you turn Lengthy paperwork to complete to initiate services Physical environments that are not conducive to healing Barriers to receiving services, lack of flexibility in serving the clients Behavior management that include restraints, seclusion, or chemical sedation such as injections!

20 What are Trauma-Specific Interventions? Trauma-specific interventions are designed to address the consequences of trauma on the person impacted. The questions shifts from What s wrong with you? to What happened to you? Competent trauma assessment is the first step. TAP (Trauma Assessment Pathway), Trauma Symptom Checklist, Parenting Stress Index, UCLA PTSD Index Traditional psychotherapy may not be the best, most effective approach to use with children and youth. Research has shown that CBT techniques have been the most effective in helping children and youth overcome trauma. Trauma specific interventions create safety first through relationship and focuses on strengths. Culturally competent and developmentally appropriate services are key components After safety is established, emotional regulation is key-helping youngsters learn to control their overwhelming emotions.

21 Interventions, continued Psycho-education is an important part of intervention. Children, adolescents and their parents/caregivers need to know the impact of trauma on their development, behavior and relationships in developmental terms they can understand. Other information is equally important-i.e., social skills building, anger management techniques, communication skills, healthy relationships, leisure skill development and planning, sex education, etc. Interventions should assist the child/youth with finding new meaning to their trauma history and current experiences.

22 Interventions, continued Trauma narratives/storytelling help the child master the painful feelings of the trauma and assist them in overcoming the impact. It can change the way they feel about their history Establish a Comfort Plan (crisis plan) with clients guiding this process. Comfort plan should include triggers, early warning signs and strategies to provide relief. This plan should be posted in multiple places, laminated for a pocket version, hung on the frig, given to school staff, really anyone involved in child/youth s life should have a copy. Any trauma focused intervention should assist the client with looking at how to enhance resiliency and social integration successfully. What is your plan? What are the steps to make this plan alive?

23 Empirically supported trauma focused interventions Alternatives for Families-A Cognitive Behavioral Therapy (AF-CBT); individual, family Assessment-Based Treatment for Traumatized Children: Trauma Assessment Pathway (TAP); individual, family, systems Attachment, Self-Regulation and Competence (ARC): A Comprehensive Framework for Intervention with Complexly Traumatized Youth; individual, family, systems Neurosequential Model of Therapeutics (NMT): individual, family Parent-Child Interaction Therapy (PCIT): individual, family, systems

24 Empirically supported trauma focused interventions, cont. Sanctuary Model; individual, family, systems Sanctuary Model Plus; RTC Seeking Safety; parent/group Structured Psychotherapy for Adolescents Responding to Chronic Stress (SPARCS); group Trauma-Focused Cognitive Behavioral Therapy (TF- CBT); individual, family Trauma-Focuses Coping in Schools; individual, group Trauma Systems Therapy (TST); systems

25 Treating the trauma Treatment services should be addressing the trauma not solely focusing on the child/youth s behaviors Be wary of insisting that medications be adjusted, reviewed, changed. Medications do NOT cure/reduce the effects of trauma. They serve to assist with symptom management. A numb person can t feel therefore can t heal. Caregiver (bio family, kin, foster parent, adoptive) training and family therapy is critical to healing

26 Questions to ask What are the child s trauma symptoms? How is the trauma being addressed in the child/youth and family? Which TF evidenced based practices are being provided to the child/youth and/or family? What are the barriers to accessing services that are trauma focused? What is the comfort plan/crisis plan for the child/youth/parent? Do they have one? Are the interventions based on developmental age, culturally competent?

27 Benefits of TI/TF services Reduces parental abuse-related fear Decreases depression and anxiety Increase overall behavioral functioning Increases child safety skills Increases productive parenting skills Decreases risk of juvenile justice involvement, substance abuse, underage pregnancy Increase affect regulation Long term studies are underway

28 SO what about YOU??? Vicarious trauma is real. It is what happens to you over time as you witness cruelty and loss and hear distressing stories, day after day, and year after year. Simply put, it changes you. ALL OF US. Symptoms are: Hyper arousal-trouble sleeping, concentrating, easily startled Problems managing the boundaries between yourself and others (e.g., taking on too much responsibility, having difficulty leaving work at the end of the day, trying to step in and control other s lives) Increased sensitivity to violence; fear Physical problems such as aches & pains, illnesses, accidents Difficulty feeling connected to what s going on around and within you; Cynicism; loss of idealism; anger; disgust Loss of meaning and hope = APATHY. Silencing response

29 Taking care of YOU Relate, Rest and Relax ESCAPE and UNPLUG Work protectively- Know why you are sitting at the table; know your role and mission; do you have what you need to do this job? how do you measure success? what can you control? Get supervision Transform your VT by finding new meaning and purpose Remind yourself of the importance and value of the work we do Stay connected with family, friends, and colleagues; Noticing and deliberately paying attention to the little things small moments like sipping a cup of coffee, the sound of the wind in the trees, or brief connections with others Marking transitions, celebrating joys, and mourning losses with people you care about through traditions, rituals, or ceremonies Taking time to reflect (e.g., by reading, writing, prayer, and meditation) Identifying and challenging your own cynical beliefs Get training, learn something new, writing in a journal, being creative and artistic; move your body

30 Resources and References Debling, et al., (2011). Trauma-focused CBT for children: Impact of the TN and length. Depression and Anxiety, Vol. 28, issue 1, pp Ferris, (2011). Increasing the accessibility of TF services to children. Wilder Research: St.Paul, MN. Rich, et al., (2009). Healing the Hurt: Trauma-Informed Approaches to the Health of Boys and Young Men of Color. Drexel University, School of Public Health. Bloom and Sreedhar, (2008).The Sanctuary Model of Trauma-Informed Organizational Change. Reclaiming children and youth, Vol. 17, number 3. NC Division of Social Services and the Family and Children s Resource Program, Practice Notes, Volume 17, Number 2, May 2012., FFTA, (2008). Implementing Evidenced-based practice in Treatment Foster care.

31 Resources and References The National Child Traumatic Stress Network SAMHSA Headington Institute National Center for Trauma Informed Care Center for Study of Traumatic Stress

32

33 The Up Center