Trauma-Informed Care: Key Concepts and Core Principles

Transcription

1 Trauma-Informed Care: Key Concepts and Core Principles Deana Leber-George, M.Ed., LPCC-S Consultant and Trainer

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5 Learning Objectives 1. Define Trauma and its neurobiological basis, including its relationship to mental illness, substance use disorders and medical conditions. 2. Describe Trauma-informed and trauma-specific approaches to care in populations with mental illness and substance-use disorders. 3. Identify strategies to increase the implementation of traumainformed and trauma-specific approaches to care in behavioral health agencies and systems.

6 Where in your life do you feel a threat where there is no longer a danger?

7 SAMHSA s Concept of Trauma Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual s functioning and mental, physical, social, emotional, or spiritual well-being.

8 Trauma Affects Over one out of three females with mental health disorder; and About one out of five males with mental health disorder in Ohio 8

9 Trauma Affects Over one out of four females with a substance use disorder; and About one out of ten males with a substance use disorder in Ohio 9

10 Prevalence of trauma NIDA suggests that up to two thirds of individuals with substance use disorders have experienced trauma!! Rape victims are three times more likely to use marijuana, six time more likely to have used cocaine and ten times as likely to have used other drugs, including heroin and amphetamines 10

11 THE THREE E S OF TRAUMA: EVENT(S), EXPERIENCE OF EVENT(S), AND EFFECT DSM-5 requires all conditions classified as trauma and stressor-related disorders to include exposure to a traumatic or stressful event as a diagnostic criterion The individual s experience of these events or circumstances helps to determine whether it is a traumatic event. A particular event may be experienced as traumatic for one individual and not for another Examples of adverse effects include an individual s inability to cope with the normal stresses and strains of daily living; to trust and benefit from relationships; to manage cognitive processes, such as memory, attention, thinking; to regulate behavior; or to control the expression of emotions

12 ACE Pyramid 12

13 ACE Categories (Felitti) Abuse Neglect Household Dysfunction Health Risk Abuse Emotional Physical Sexual Neglect Emotional Physical Household Dysfunction Mother Treated Violently Household Substance Abuse Household Mental Illness Parental Separation or Divorce Incarcerated Household Member 13

14 ACE Score Calculator While you were growing up, during your first 18 years of life: 1. Did a parent or other adult in the household often or very often Swear at you, insult you, put you down, or humiliate you? Or Act in a way that made you afraid that you might be physically hurt? Yes-No 1 point for Yes 2. Did a parent or other adult in the household often or very often Push, grab, slap, or throw something at you? Or Ever hit you so hard that you had marks or were injured? Yes-No 1 point for Yes 3. Did an adult or person at least 5 years older than you ever Touch or fondle you or have you touch their body in a sexual way? Or Attempt or actually have oral, anal, or vaginal intercourse with you? Yes-No 1 point for Yes 4. Did you often or very often feel that No one in your family loved you or thought you were important or special? Or Your family didn t look out for each other, feel close to each other, or support each other? Yes-No 1 point for Yes 5. Did you often or very often feel that You didn t have enough to eat, had to wear dirty clothes, and had no one to protect you? Or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it? Yes-No 1 point for Yes 6. Were your parents ever separated or divorced? Yes-No 1 point for Yes 7. Was your mother or stepmother: Often or very often pushed, grabbed, slapped, or had something thrown at her? Or Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? Or Ever repeatedly hit at least a few minutes or threatened with a gun or knife? Yes-No 1 point for Yes 8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs? Yes-No 1 point for Yes 9. Was a household member depressed or mentally Did a household member attempt suicide? 10. Did a household member go to prison? Yes-No 1 point for Yes Yes-No 1 point for Yes Add up Yes answers: This is your ACE Score. 14

15 ACE Score and Health Risk As the ACE score increases, risk for these health problems increases in a strong and graded fashion: Alcoholism and alcohol abuse Chronic obstructive pulmonary disease (COPD) Depression Hallucinations Fetal death Decline in Health-related quality of life Illicit drug use Ischemic heart disease (IHD) Liver disease Risk for intimate partner violence Multiple sexual partners Sexually transmitted diseases (STDs) Smoking Suicide attempts Unintended pregnancies Early initiation of smoking Early initiation of sexual activity Adolescent pregnancy HIV 15

16 Childhood experiences and adult alcoholism 16

17 ACE score and IV drug use 17

18 Effects of Trauma on Neurocognitive Development 18

19 When our Anterior Cingulate Cortex shuts down (During periods of anxiety and depression) We cant process SENSORY data So we rely on LEARNED data. Every painful learning experience is encoded in our frontal lobe.. Painful learning hi-jacks perception During periods of hypervigilance less strong; less intelligent & strategic Relaxed vigilance (trust of self) optimizes performance

20 6 KEY PRINCIPLES OF A TRAUMA-INFORMED APPROACH 1. Safety physical and psychological 2. Trustworthiness and Transparency with clients, family, and staff 3. Peer Support utilizing the lived experience as vehicle for recovery 4. Collaboration and Mutuality partnering/leveling of power differences 5. Empowerment, Voice and Choice strength, resilience, shared decision-making 6. Cultural, Historical, and Gender Issues Adult trauma = wound Childhood Trauma = structure of being; no self was developed yet its all reaction to perceived threat of being.

21 4 Assumptions of the Trauma-Informed Approach: The 4 Rs A program, organization, or system that is trauma-informed: Realizes the widespread impact of trauma and understands potential paths for recovery Recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system Responds by fully integrating knowledge about trauma into policies, procedures, and practices and seeks to actively Resist Re-traumatization

22 Realization Trauma can affect families, groups, organizations, and communities as well as individuals. People s experience and behavior are understood in the context of coping strategies designed to survive adversity and overwhelming circumstances. Trauma may have occurred in the past, may be currently manifested, or related to the emotional distress that results in hearing about the firsthand experiences of another. Trauma plays a role in mental and substance use disorders and should be systematically addressed in prevention, treatment, and recovery settings. 22

23 Realization Questions to Consider Do I realize that behaviors of clients and staff maybe coping strategies and defense mechanisms for current or past traumas? How might someone s defense mechanism of anger or social avoidance help them cope from past trauma? 23

24 Recognition Signs of trauma may be gender, age, or setting-specific. Signs of trauma may be manifest by individuals seeking - or - providing services in these settings. Trauma screening and assessment assist in the recognition of trauma. Workforce development and supervision practices assist recognition of these signs. 24

25 Recognition Questions to Consider How do you help people recognize the immediate and delayed signs of trauma? Physical Emotional Cognitive Social/interpersonal Behavioral Existential 25

26 Response Apply the principles of a trauma-informed approach to all areas of organizational functioning. The experience of traumatic events impacts all people involved, whether directly or indirectly. Change language, behaviors and policies to take into consideration the experiences of trauma among children and adult users of the services and among staff providing the services. Training includes resources for mentoring supervisors on helping staff address secondary traumatic stress. The organization is committed to providing a physically and psychologically safe environment. Leadership ensures that staff work in an environment that promotes trust, fairness and transparency. 26

27 Response Questions to Consider How do you ensure an environment that is physically and psychologically safe? Has your organization implemented universal screening and assessment for trauma? Do you have access to and supervision for trauma-specific services from a skilled person? Do you offer peer support at your organization? How do you ensure continuity of care between organizations and across systems? Does your organization/supervisors help staff members address stress from secondary trauma? How transparently does your organization conduct operations and treatment planning? 27

28 Resist re-traumatization Organizations often inadvertently create stressful or toxic environments that interfere with the recovery of clients the wellbeing of staff and the fulfillment of the organizational mission. Teach staff to recognize how organizational practices may trigger painful memories and re-traumatize clients with trauma histories. 28

29 Trauma-Informed Care Promotes Cultural Change What happened to you? instead of What s wrong with you? WHY IS THIS IMPORTANT? Clients don t have pathology they have adaptation (over adaptation) Trauma informed means that you understand that the persons responses are completely appropriate in their circumstances and perception..

30 Trauma-Informed Treatment Objectives Establish Safety Build Trust Support Empowerment Prevent Re-traumatization Identify and Manage Trauma- Related Triggers Normalize Symptoms Acknowledge Grief and Bereavement Draw Connections Build Resilience Address Sleep Disturbances Teach Balance Provide Psychoeducation Offer Trauma-Informed Peer Support Monitor and Facilitate Stability

31 Effects of trauma Trauma affects Client Presentation Client Engagement = how do you think? Client Outcomes Traumatic stress reactions are NORMAL reactions to ABNORMAL circumstances Not everyone who experiences trauma will develop PTSD

32 Range of trauma reactions Some are behavioral vs. reflective (internal) Some emotionally expressive vs. very private Not all survivors need to talk about the trauma Respect & value the individual s style of coping Also: trauma reactions vary depending on whether events were singular, multiple, or enduring

33 What is foreshortened future? Sometimes, because of trauma, there is: Loss of hope Limited expectations about life Fear that life will end early or abruptly Thinking that normal life events simply won t happen for them school work close meaningful relationships

34 Understanding the impact of trauma Immediate Reactions & PHYSICAL EMOTIONAL COGNITIVE EXISTENTIAL IMPACT of TRAUMA BEHAVIORAL DEVELOPMENTAL SOCIAL

35 ON A SCALE FROM 1 TO 10 WHAT IS YOUR COMFORT LEVEL AROUND TRAUMA RELATED ASPECTS WITHIN THE PEOPLE YOU PROVIDE CARE?

36 Why Providers Avoid Screening for Trauma. Underestimate impact of trauma Belief that treatment should focus only on presenting symptoms Belief that substance use disorders should be treated first and exclusively Lack of training/ feeling incompetent Not knowing how to respond therapeutically Fear that screening will be too disturbing to clients Not using common language with clients Insufficient time Staff s own untreated trauma-related symptoms

37 Trauma-Informed Approach vs. Trauma-Specific Services Trauma-Informed All people at all levels of the organization or system understand how trauma can affect families, groups, organizations, and communities as well as individuals Refers to organizational culture Trauma-Specific Refers to specific interventions, whether assessment, treatment or recovery supports

38 Trauma-Specific Services Present-focused vs. Past-focused (Forward Facing Focus) Present-focused: current coping skills, psychoeducation, and managing symptoms for better functioning Past-focused: telling the trauma story to understand the impact of the trauma on how the person functions today, and experiencing emotions that were too overwhelming to experience in the past Only address original trauma if it intrudes in present functioning and the following interventions don t help refocus to present.

39 Trauma-Specific Treatment Models 1) Cognitive-Behavioral Therapy 2) Cognitive Processing Therapy 3) Exposure Therapy 4) Eye Movement Desensitization and Reprocessing (EMDR) 5) Narrative Therapy 6) Skills training in affective and interpersonal regulation (STAIR) 7) Stress inoculation training

40 But I m not.clinically trained Take focus off of what is OUT of control and place focus on what is IN control 1 st most influential influence in trauma therapy =???? 2 nd and 3 rd most influential influence in trauma therapy =???? DON T BECOME AN INSTRUMENT OF PALLITIVE CARE!!! Must learn to use language in a way to offer alternative to the death march that they are on.

41 What is necessary? 6 empirical markers (Gentry 2016) 1. Resolve Real Danger 2. Distinguish between real and perceived threat 3. Develop battery of regulation/relaxation, grounding and containment skills 4. Demonstrate ability to self regulate and self-rescue* 5. Contract to address traumatic material* 6. Non anxious presence = good prognosis* * Not necessary in forward facing trauma work

42 Active Ingredients to Healing Trauma 1. Therapeutic Relationship 2. Relaxation 3. Exposure / Narrative 4. Cognitive Re-Structuring

43 Therapeutic Relationship The client is always stronger than us more resilient They will kill themselves before they will allow us to Make them do or be anything Lack of connection to a therapist that is judgmental and disregulated is GOOD judgement on their part. Left to our own devices therapists will take the low road.not because we are bad - we re tired. L We start killing gnats with bazookas

44 Therapeutic Relationship: Clarify expectations Create an Effective Environment Physical/psychological reactions may last for hours to a few days (this is normal!) Don t extort trust - I don t want you to trust me I want you to trust YOU. Remain matter-of-fact yet supportive Respect the person s personal space Adjust tone/volume of speech

45 Therapeutic Relationship: Create an Effective Environment Be aware of your own responses to hearing clients trauma histories Proper use of interpreters do not use family or friends!)

46 Therapeutic Relationship: Create an Effective Environment Elicit only the necessary information Serve as gatekeeper to preserve safety Don t probe too deeply yet avoid conveying the message I don t want to hear about it Example of appropriate statement (TIP 57, page 97) Your life experiences are very important, but at this stage in our work together, we should start with what s going on in your life currently rather than discussing past experiences in detail.let s keep the focus on your safety and recovery right now.

47 Therapeutic Relationship: Create an Effective Environment Emphasize personal control Option of being interviewed by a particular gender Postponing interview if necessary The right to refuse to answer any/all questions Self-administered written checklists rather than interviews, when possible Except if trouble reading or filling out checklist

48 Therapeutic Relationship: Create an Effective Environment Allow time for client to become calm and oriented after an intense emotional response (TIP 57 Grounding Techniques p98) 1. Ask the client to state what he or she observes. 2. Help the client decrease the intensity of affect. 3. Distract the client from unbearable emotional states. 4. Ask the client to use breathing techniques.

49 Therapeutic Relationship: Create an Effective Environment Avoid phrases that imply judgment about the trauma Provide feedback about the results of the screening Be aware of possible legal implications of screening/assessment

50 Psycho-Education Start to construct internal structure around external chaos. Teach them about their own CNS

51 Psycho-Education Rebuild Perceptions and Perspectives Allow them to turn it into language help give them language Guilty feelings can be ameliorated by a behavior Change behavior Apology Admission of guilt Shame is not a feeling it s a judgement Continual MEANING from traumatic event.

52 Healing = Rebuilding Perceptions and Perspectives Teach the difference between feeling safe and being safe Raise awareness Fight or flight (Annilate or escape) never allows for healing Your own past is intruding to intensely interfere with your current perception of reality.

53 Healing = Rebuilding Perceptions and Perspectives It s all in my control We only need to learn to trust ourselves My brain works in cooperation with me if I learn to live with my Autonomic Nervous System

54 Healing = Rebuilding Perceptions and Perspectives Last milestone of adulthood = To learn to confront the perceived threats of daily living inside of us in a relaxed muscle body with full neocortex functioning

55 Go Beyond Normalization Optimalization If I described to you exactly what proper grief looks like you re doing it. People seeking trauma/grief counseling are often looking for circumnavigate Impossible must go through it. Distracted by Stages of Grief Kubler Ross are stages of DYING not grief!

56 Grief Grief is not a pathological condition so there is no treatment. What is goal then???? What are the things we have to offer to achieve this goal? Grieving allows us to heal, to remember with love rather than with pain.

57 4 Tasks of Mourning 1. Accept the reality of the loss Try to call it to mind in a relaxed body 2. Process the pain of the grief Needs to be turned into language, shared and processed 3. Adjust to a world without the deceased / object Internal, external, spiritual, behavioral 4. Find an enduring connection w deceased/object in midst of embarking on a new life.

58 Self regulation Survivors of trauma (including US) have been in such a state of constriction for so long that they loose the awareness of and the knowledge surrounding how to relax. Stress = biofeedback It s our bodies way of asking us to RELEASE IT Interoception ability to have a real time sense of what is really happening in your body.

59 Self- regulation Can not be stressed and relaxed at the same time. Take attention out of your head and put it into your body 1. Peripheral vision 2. Pelvic Floor Relaxtion 3. Soft Palate Relaxation 4. Diaphragmatic Breathing

60 Self regulation Difference between relaxation techniques and self regulation techniques

61 Negative Self-Talk Be the author of your own thoughts. What kind of talk would you LIKE to have with yourself? Endure positive affirmations Spend time listing the good things Ask to share with them a list of good things

62 Write a Convenant Write a Statement of Purpose Why are you alive? What is your life about?

63 Develop a Code of Honor What Principles guide your integrity? Who would you chose to be if it was up to you? How will you be that person?

64 Graphic Time Line Creates an organic relational experience 3-5 Positive experiences 3-5 Negative experiences

65 Safe Place Picture with Anchoring/Transitional Object Draw a picture of a place that is safe and comfortable. Real from memory Constructed from imagination Give transitional object Describe the place

66 Trauma Informed Self Care

67 Resilience Merriam- Webster Dictionary The ability to become strong, healthy, or successful again after something bad happens The ability of something to return to its original shape after it has been pulled, stretched, pressed, bent, etc. Finding mission post combat

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69 We exert so much energy trying to get everyone else to change or bend to our world widen the space between stimulus and response. We must learn to exist in our own regulated ANS. Practice the PAUSE!

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71 The experience of feeling overwhelmed, overworked and possibly even traumatized are so common that we now have names to better explain them... Burnout Secondary Stress/Trauma Compassion Fatigue Vicarious Trauma

72 Important Hallmarks of Vicarious Trauma Physical manifestations Attitude; Humor turns to true negativity Passion shifts; Change in worldview Loosing the capacity to believe that we can make change. (Connie Burk)

73 Ideas for Addressing Burnout Being aware of a shift in ones usual perspective towards work or clients Acknowledging that a break or shift is needed (self or other) Processing Paying attention to the basics...eat/sleep Taking time for lunch...vacation...personal day Self-care

74 RESOURCES Substance Abuse and Mental Health Services Administration. SAMHSA s Concept of Trauma and Guidance for a Trauma-Informed Approach. HHS Publication No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration, Substance Abuse and Mental Health Services Administration. Trauma- Informed Care in Behavioral Health Services. Treatment Improvement Protocol (TIP) Series 57. HHS Publication No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration, Gentry, J.E. (2016) Trauma Competency Conference: The 10 Core Competencies for Trauma, PTSD, Grief and Loss.

75 Deana Leber-George, M.Ed., LPCC-S Consultant and Trainer Center for Evidence-Based Practices Case Western Reserve University Euclid Avenue Cleveland, Ohio