by SafePlace, Disability Services ASAP (A Safety Awareness Program) 1

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1 Trauma-Informed Care A Survivor-Centered Approach Disability Services ASAP (A Safety Awareness Program) Why are we here? To explore how trauma-informed values and principles can support survivor-centered approaches and support survivors of multiple traumas in gaining and maintaining access to services that support healing. Why be informed about trauma? Trauma is pervasive The impact of trauma is broad and diverse Results of trauma are deep and life-altering Trauma affects how people approach life and relationships Service systems can be re-traumatizing Fallot, R.D., Jan 28, Paper presented at Institute of Medicine Conference. Washington, DC. Services ASAP (A Safety Awareness Program) 1

2 What is Trauma? Trauma is a person s response to an event that involved intense fear, horror and a sense of helplessness. The person experiences extreme distress and stress that overwhelms their ability to cope. And, a traumatic event overwhelms our nervous systems capacity to have a sense of control over ourselves and our environment, to maintain our connection with other people and to make meaning out of the experience. A Traumatic Event A traumatic event is any event that is distressful, painful, and disrupts and overwhelms a person s nervous system. The trauma is what happens in the nervous system not the event itself. Herman, J. 1992; Trauma and Recovery, Harper Publishing. The ACE Study As a result of one of the most comprehensive studies of its kind, conducted by the Centers for Disease Control and Kaiser Permanente Health Systems, evidence is available that the effects of violence and trauma in childhood when there is no intervention can result in chronic physical and mental health difficulties in adulthood. Further, this violence can continue across generations when there is no intervention to interrupt the cycle. The ACE Study: Services ASAP (A Safety Awareness Program) 2

3 Unfortunately many of these same survivors of trauma and sexual violence have the most difficult time gaining and maintaining access to healing/recovery services they need, or they end up being re-traumatized and further abused by the systems they turn to for help. -Edmund, 2011 What is Trauma? WHEN TOO MUCH HAPPENS TOO FAST! Social Engagement Mind and Body Perception that the Situation is Life Threatening Threat to the Physical Integrity of Self and Others Event or Series of Events Freeze Fight Flight Person s Nervous System is Overwhelmed Intense Terror Intense Helplessness Intense Hopelessness Loss of Control Practically Speaking Trauma survivors can have difficulty with. Control/self-regulation Moods/emotions Ability to be present Relationships/social situations Substance abuse Holding a job Keeping secure housing Staying connected to healing services Services ASAP (A Safety Awareness Program) 3

4 In the words of Peter Levine (2010), trauma is not what happens to us, but what we can hold inside about what happens to us. When we experience danger without possibility of defending ourselves through fight or flight, and then if after the danger is past we do not have an opportunity to resolve that defensive response (when we can t shake it off) we can experience a physical and emotional shutdown and a sense of helplessness in the face of danger. Based on the work of Peter Levine work and Somatic Experiencing (SETI); Material developed by Maggie Kline & Kris Downing Fight, Flight or Freeze? Based on the work of Peter Levine work and Somatic Experiencing (SETI); Social Engagement Flight / Fight Services ASAP (A Safety Awareness Program) 4

5 What can fight or flight look like? Argumentative Engaging in power struggles Verbal aggression Overreacting / angry outbursts Overly talkative Hyperactivity Restlessness, leaving / running Based on the work of Peter Levine and Somatic Experiencing (SETI); Material developed by Maggie Kline & Kris Downing What Can Freeze Look Like? Being distracted, daydreaming, forgetful Difficulty planning and organizing Headaches, stomach problems Low energy, fatigue Isolating, withdrawing, few friends Sense of helplessness, crying spells Extreme sensitivity to noise environments Substance abuse Based on the work of Peter Levine and Somatic Experiencing (SETI); Material developed by Maggie Kline & Kris Downing Services ASAP (A Safety Awareness Program) 5

6 Being stuck in past survival modes after the danger is over makes it difficult to feel safe and focus in the present time. When a person begins to live in this state, events that may typically be only mildly irritating or intrusive or even just a challenge to be dealt with can result in overwhelming feelings of threat and dread. This disruption in the nervous system can create a host of symptoms (e.g., hyper-arousal, dissociation, self-blame, hopelessness, helplessness, depression, constriction, etc.). Based on the work of Peter Levine work and Somatic Experiencing (SETI); Principles of Trauma-Informed Care 1. Recognize impacts of trauma on development/coping strategies 2. Identify recovery as a primary goal 3. Recognize and respect survivors rights to make choices 4. Seek survivor input in designing and evaluating services 5. Strive to maximize choice and control over as much of their own recovery as possible. 6. Create atmospheres of respect for needs of safety and acceptance 7. Emphasize strengths and highlight adaptations instead of symptoms and the survivors resilience instead of mental illness 8. Minimize possibilities for re-traumatization 9. Strive to understand each survivor in the context of her/his life experiences and cultural background. Elliott, D.E., Bielajac, P., Fallot, R.D., Markoff, L.S., and Glover Reed, B. (2005). Services ASAP (A Safety Awareness Program) 6

7 Trauma-Informed Perspective Instead of asking, What is wrong with you?, trauma-informed care providers ask: What happened to you? Trauma-Informed Care Trauma-informed care is an approach to engaging children and adults with histories of trauma that recognizes the impact of trauma, the effects of trauma and acknowledges the role that trauma has played in the survivor s life. Services are directed by a thorough understanding of the profound biological, neurological, psychological and social effects of trauma and sexual violence on survivors. Services ASAP (A Safety Awareness Program) 7

8 Trauma-Informed Organizations Understand the unique vulnerabilities and triggers experienced by trauma survivors that traditional service delivery approaches may worsen. Respond to survivors of trauma with supportive intent and consciously avoid re-traumatization Ensure the environment is physically and emotionally safe. Trauma-Informed Values Safety: Will I be safe here and with you physically and emotionally? Trustworthiness: Can I believe in you to tell me the truth and be honest? Choice: Will I be able to make decision or are you making all of the decisions for me? Collaboration: Will you tell me what to do or will you work with me? Empowerment: Will you support me to find and use my own voice? Adapted from Fallot, R.D., (2011) Washington, DC. Paper presented at Institute of Medicine Conference. Services ASAP (A Safety Awareness Program) 8

9 One way I can integrate the core values of trauma-informed care into my work with sexual assault survivors is One thing I will do differently is Universal Precautions A Core Trauma-Informed Concept Presume that every person in a helping setting has been exposed to some form of abuse, violence, neglect or other traumatic experiences. Services ASAP (A Safety Awareness Program) 9

10 Neurobiological Interventions/Supports 1. Caring emotional support is key to helping survivors: it brings the Hypothalamus; Pituitary; Adrenal (HPA) system down 2. Simple and kind gestures 3. Provide information about options and time to make decisions give time 4. Empowerment making choices/decisions helps develop the frontal cortex of the brain Campbell, R., 2012, NIJ Neurobiological Interventions/Supports 1. Safe physical contact lowers cortisol 2. Positive attachments directly re-wires the frontal cortex of the brain which mediates emotional responses and balances the nervous system 3. Be aware that when survivors don t behave according to expectations, they are much less likely to be believed and may be: accused of lying or making false reports; Interviewers/investigators may note disbelief in reports; they are less likely to follow up Campbell, R., 2012, NIJ Neurobiological Interventions and Supports Break up routines Challenge the brain to learn new tasks Engage in activities that combine senses (music/dance) Grounding with animals/pets Provide opportunities for creative expression for survivors and their children. Massage Meditation Physical exercise Sleep Yoga Campbell, R., 2012, NIJ Services ASAP (A Safety Awareness Program) 10

11 Trauma-Informed Organizations and Environment View trauma responses as adaptations and not as pathology, or attention seeking or manipulation. Post information about the impacts of trauma in visible places. Provide access to counselors/therapists with expertise in trauma and trauma-related interventions. Give survivors priorities weight in terms of services received and goals established. Ensure there are no negative consequences for exercising particular choices about goals and services. Create opportunities for current and former clients to make anonymous suggestions for improvements in your services. Trauma-Informed Organizations and Environment Recruit former clients in designing and providing services (i.e., peer support programs). Create safe opportunities for staff to talk about how their work is affecting them. Provide information on secondary trauma and self-care for all level staff. Develop or provide options for education and training on topics that increase staff confidence and competency in the area of trauma-informed services. Safe Relationships There is no more effective neurobiological [or trauma-informed] intervention than a safe relationship. -Bruce Perry Services ASAP (A Safety Awareness Program) 11

12 References Burgess, W., 1991 (editor). Neurobiology of Tape, Trauma (From Rape and Sexual Assault III, p See NCJ Campbell, R., (December 2012). Implications for First Responders in Law Enforcement, Prosecution, and Victim Advocacy. NCJ Elliott, D. E., Bjelajac, P., Fallot, R. D., Markoff, L. S., and Glover Reed, B. (2005). Trauma-Informed or Trauma-Denied: Principles and Implementation of Trauma-Informed Services for Women. Journal of Community Psychology, Vol. 33, No. 4, Published online in Wiley InterScience ( DOI: /jcop Fallot, R.D. and Harris, Maxine (2010). Creating Cultures of Trauma-Informed Care (CCTIC): A Self-Assessment and Planning Protocol. References Gillece, Joan (2010). Understanding the Effects of Trauma. Presented at the National Association of State Mental Health Directors, National Technical Center. Harris, Maxine and Fallot, Roger D. (2001). Using Trauma Theory to Design Service Systems. New Directions for Mental Health Services, Number 89, Spring, San Francisco: Jossey-Bass. King Akers, Dianne, Schwartz, Michelle Shell, and Abramson, Wendie H. (2007). Beyond Labels, Working with Abuse Survivors with Mental Illness Symptoms or Substance Abuse Issues. SafePlace, Austin, Texas. Levine, Peter A. (2010). In An Unspoken Voice, How the Body Releases Trauma and Restores Goodness. North Atlantic Books. Berkeley, California. References Moving Forward in Challenging Times, Exploring our Collective Capacity for Trauma-Informed Service Delivery: A National Conference Proceedings Document (2012). Saakvitne, Pearlman & Staff of TSI/CAAP (Norton, 1996). Transforming the Pain: A Workbook on Vicarious Traumatization. Traumatization-Professional/dp/ Self-Care Assessment Worksheet in Transforming the Pain: A Workbook on Vicarious Traumatization cited above. The ACE Study: The Anna Institute: Services ASAP (A Safety Awareness Program) 12

13 Michelle (Shell) Schwartz Voice: Rebakah Adams Voice: This presentation is based, in part, on information published in Beyond Labels: Working with Abuse Survivors with Mental Illness Symptoms or Substance Abuse Issues 2007 SafePlace For more information, visit the SafePlace website, Questions for use in planning with and supporting survivors to identify ways to cope with crisis: 1. What makes you feel scared or upset or angry and causes you to go into defense or emergency mode? 2. What are some observable ways you may show that you are distressed or overwhelmed? 3. What are some specific responses or strategies that are helpful to you when you are overwhelmed? 4. Who are the people you feel safe around and can go to or contact for support or comfort? 5. What is not helpful when you are triggered and/or in a defense or emergency mode (fight, flight, or freeze)? Joan Gillece, 2010 Services ASAP (A Safety Awareness Program) 13

14 Education and Training Topics 1. Understanding behavior through a trauma-informed lens 2. How trauma impacts child development and attachment 3. Basic techniques for grounding, de-escalation and selfsoothing (for survivors and staff) 4. Basic strategies for trauma-informed de-escalation and calming 5. Intersections of trauma, substance use and mental health 6. Recognizing and managing individual triggers. 7. Techniques for helping survivors manage feelings of helplessness, rage, sadness and terror. Services ASAP (A Safety Awareness Program) 14