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1 CO Refugee Services Program (CRSP) Trauma Informed Care Training Facilitators DAY 1 Melinda Marasch, LCSW (303) Melinda@Aspire2BU.org Shawn B. Young (720) shawn@fhinst.com Day 1 Agenda Careful Introduction Stress Scarcity Wellness (Self Care) Talking about stress & trauma can be stressful. Integration & Wrap Up It s About the Clients via the Staff Why Are We Here? I N T R O D U C T I O N You are Dedicated Compassionate Hard working Strong/Survivors? Document and content not to be used without permission 1

2 Some Understanding of Clients/Scenarios Trauma Informed Care Clients cry, get angry, upset, etc. Using formal & informal translation is a barrier You don t always have the means to address client situations (e.g. inadequate income, mental health issues) You have to say no, give bad news or news the client doesn t like to hear It is difficult to deal with disrespect, entitlement, reluctance, resolve, etc. Capacity (time, etc.) is an issue in providing care The American Dream isn t all it s supposed to be? Strengths-based service delivery approach Grounded in an understanding of and responsiveness to the impact of trauma Emphasizes physical, psychological, and emotional safety for both providers and survivors Creates opportunities for survivors to rebuild a sense of control and empowerment Involves vigilance in anticipating and avoiding institutional processes and individual practices that are likely to re-traumatize individuals who already have histories of trauma Upholds the importance of consumer participation in the development, delivery, and evaluation of services SAMHSA (2014) Stress Trauma is not a disease but a dis-ease. -Levine & Frederick (1997, p. 37) An elevation in a person's state of arousal or readiness, caused by some stimulus or demand. Moderate stress arousal improves health and performance Manageable stress levels can sharpen attention & mobilize our physical ability to cope with threats At some point, stress arousal reaches maximum effect & all that was gained by stress arousal is lost and deterioration of health and performance begins (Luxart Communications, 2004). SAMHSA (2005) Traumatic Stress Scarcity Trauma involves some sort of overwhelming experience that goes beyond usual day to day stressors. Involves some sort of threat, either to ourselves or to a loved one Overwhelms our usual systems of coping Results in a sense of vulnerability and a loss of control Leaves people feeling helpless and fearful Scarcity is defined as a feeling If that feeling of Scarcity leads to a physiological response, the person would then be experiencing stress. May adversely affect people s relationships and ways of thinking about the world over time SAMHSA (2005) Document and content not to be used without permission 2

3 What Does It Mean for You? Keep trauma in mind Know what you re doing & why Utilize best practices SAMHSA s Eight Dimensions of Wellness Source: Adapted from Swarbrick, M. (2006). A wellness approach. Psychiatric Rehabilitation Journal, 29(4), Learning Objectives This Training Might Help You 1. Understand Rational Behavior Economics (scarcity, etc.) 2. Explain 1 term related to Trauma Informed Care (i.e. stress, trauma, compassion fatigue, etc.) 3. Explain 3 ways stress/trauma might impact refugees and immigrants 4. Recall 1 thing about how change happens 5. Understand how to define success 6. Explain the Motivational Interviewing (MI) Spirit 7. Identify 1 of 5 MI Processes 8. Identify 2 of 6 MI Approaches 9. Enhance confidence in practicing MI Approaches 10. Plan to utilize MI Approaches on the job Respond when someone cries Respond when translator is putting own spin on things/having a conversation with client w/o bringing you in Help client feel agency/cm is helpful & supportive even when you don t have the fix/answer Keep the client coming back even when agency/cm doesn t have the fix/answer Help the client ask for appropriate help (how, when, who, etc.) Help clients engage with other providers Support client while also completing required tasks Deal with disillusionment of the American Dream (low & high English & skills) Define the right goals at the right time Say the same thing 100x &/or place responsibility on client (independence) Give bad news Be professional/respectful when someone is mean/rude Motivate people to their potential Help people come to their own conclusions Foster more independence in clients Integration Ahh, the Fun Part! Introduce yourself Name, position, etc. Why are you here (i.e. what are you hoping to get from the TIC trainings)? Document and content not to be used without permission 3

4 S H A W N B. Y O U N G C O P Y R I G H T S H A W N B. Y O U N G, A L L R I G H T S R E S E R V E D STRESS IN AMERICA PAYING WITH OUR HEALTH Financial Health is the dynamic relationship of one s Financial and economic resources as they are applied to or impact the state of physical, mental and social well-being. TOP 4 SOURCES OF STRESS RELEASED FEBRUARY 4, 2015 SCARCITY& STRESS FOR CLIENTS EMPLOYEES & AGENCIES SAMHSA s Eight Dimensions of Wellness Source: Adapted from Swarbrick, M. (2006). A wellness approach. Psychiatric Rehabilitation Journal, 29(4), Document and content not to be used without permission 4

5 SCARCITY AND BANDWIDTH Scarcity is defined as having less that you feel you need. (Mullainathan and Shafir) Bandwidth is our brain s computational capacity, ability to pay attention, make good decisions, stick to plans and resist temptations (Scarcity, pg. 42). SCARCITY TO STRESS Scarcity is defined as a feeling If that feeling of Scarcity leads to a physiological response, the person would then be experiencing stress. Here s what happens when we re stressed. SOME PREFERRED STRESS COPING RESPONSES Add maladaptive coping techniques WHAT DOES STRESS DO TO US ON THE JOB? 62 percent of employees have high levels of stress, with extreme fatigue/feeling out of control. 34 percent lose 1 hour or more per day in productivity due to stress. 31 percent miss 3 to 6 days per year due to stress. 15 percent miss more than 6 days per year due to stress 83 percent of employees report they are under financial stress. Evidence from two occupational cohorts suggests strong associations between economic difficulty and poor sleep. Fatigue-related productivity losses were estimated to cost $1967/employee annually. Changes in economic difficulties predict subsequent sickness absence even after considering income, baseline health and other covariates. Thus economic difficulties should be considered when addressing causes of sickness absence. ULTIMATELY, CHRONIC STRESS LEADS TO LONG-TERM HEALTH ISSUES SOME QUICK FACTS ABOUT STRESS Stress impacts cognition Your brain is built to deal with stress that lasts about 30 seconds. The brain is not designed for long term stress when you feel like you have no control. Severe stress lasting weeks or months can impair cell communication in the brain s learning and memory region. Stress lasting as little as a few hours can impair brain-cell communication as well. Stress damages virtually ever kind of cognition that exists. (Memory and executive function, cognitive capacity, motor skills, ability to sleep.) Copyright 2010 Shawn B. Young, all rights reserved STRESSED BRAINS DON T LEARN THE SAME WAY. JOHN MEDINA---BRAIN RULES Document and content not to be used without permission 5

6 STRESS IMPACTS EXECUTIVE FUNCTION We use Executive Function to direct attention, initiate an action, inhibit an intuitive response, or resist an impulse. Reduced Executive Function hampers Self-Control. The impact on Executive Function and Cognitive Capacity is important because this is where most financial and health education programs focus their efforts. There is an assumption that we are all operating at the same level all the time. ECONOMIC SHOCKS CUSHIONS & PLANS HOW DOES SCARCITY IMPACT: Tunneling is the act of focusing so intently on one issue that other issues are unable to be seen. CLIENTS EMPLOYEES ORGANIZATIONS Copyright 2014 Shawn B. Young, all rights reserved Document and content not to be used without permission 6

7 PROBLEMS WITH PLANNING: - BIASES/HEURISTICS - CHOICE ARCHITECTURE - LACK OF/INSUFFICIENT DATA - LACK OF/INSUFFICIENT EVALUATION OR REFLECTION Trauma Informed Care W H A T? How Would You Define What is Trauma? Stress Trauma Active Trauma Passive Trauma Secondary/Vicarious Trauma Burn-Out Compassion Fatigue? Definition (SAMHSA Experts 2012) includes three key elements: 1. Individual trauma results from an event, series of events, or set of circumstances 2. that is experienced by an individual as overwhelming or life-changing and 3. that has profound effects on the individual s psychological development or well-being, often involving a physiological, social, and/or spiritual impact. A Broader View of Trauma Historical trauma Intergenerational Trauma Trauma and Culture Gender and Trauma Traumatic symptoms are not caused by the triggering event itself. They stem from the frozen residue of energy that has not been resolved and discharged. This residue remains trapped in the nervous system where it can reak havock on our bodies and spirits. -Levine & Frederick (1997, p. 37) Document and content not to be used without permission 7

8 Making it Real Trauma Informed Care Brainstorm ways stress/trauma might impact clients/caregivers. Brainstorm ways stress/trauma might impact you. Strengths-based service delivery approach Grounded in an understanding of and responsiveness to the impact of trauma Emphasizes physical, psychological, and emotional safety for both providers and survivors Creates opportunities for survivors to rebuild a sense of control and empowerment Involves vigilance in anticipating and avoiding institutional processes and individual practices that are likely to re-traumatize individuals who already have histories of trauma Upholds the importance of consumer participation in the development, delivery, and evaluation of services SAMHSA (2014) SAMHSA s Four R s of TIC The 7 Domains of Trauma-Informed Care An individual, program, organization or system that is traumainformed 1. Realizes the widespread impact of trauma and understands potential paths for recovery 2. Recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system 3. Resists re-traumatization 4. Responds by fully integrating knowledge about trauma into policies, procedures, practices, and settings. 1. Early Screening & Comprehensive Assessment of Trauma 2. Consumer Driven Care & Services 3. Trauma-Informed, Educated & Responsive Workforce 4. Provision of Trauma-Informed, Evidence-Based and Emerging Best Practices 5. Create a Safe and Secure Environment 6. Engage in Community Outreach and Partnership Building 7. Ongoing Performance Improvement Understanding the Prevalence of Trauma 93% of children in detention report significant exposure to adverse events. (Abram et al., 2004); Ford et al., 2007) 50% of women in substance abuse treatment have history of rape or incest (Governor's Commission on Sexual and Domestic Violence, Commonwealth of MA, 2006) 90% of public mental health clients in have been exposed to trauma, (Mueser et al., 2004, Mueser et al., 1998) 97% of homeless women with significant mental illness have experienced severe physical & sexual abuse 87% experience this abuse both in childhood and adulthood (Goodman et al., 1997) > Behavioral responses resemble common delinquent behaviors and are under-identified as trauma symptoms > Stress manifestation is different by ages, stages, expression > Many treaters don t connect the symptoms to trauma Thus leading to punishment rather than help Document and content not to be used without permission 8

9 What is Trauma-Informed? We Begin to Ask Fosters safe, calm, and secure environment Has a working understanding of trauma prevalence, impact and trauma-informed care Strives for Cultural Competence Empowers consumer voice, choice and advocacy Believes in & supports recovery, consumer-driven and trauma specific services Focuses on healing, hopeful, honest and trusting relationships We Asked What is wrong with you? What s wrong? We Need to Ask What happened? What s strong in you? Benefits of Trauma-Informed Approaches Decisional Capacity 1. Increases safety for all 2. Improves the social environment 3. Cares for the caregivers 4. Improves the quality of services 5. Reduces negative encounters and events 6. Creates a community of hope, healing and recovery 7. Increases success and satisfaction at work 8. Promotes organizational wellness 9. Improves the bottom line Short and long term memory Executive functioning by their ability to plan, execute, and follow directions Ability to recognize risk factors Definition & appreciation of the problem Substance abuse, dementia, delirium, psychosis, traumatic brain injury, and socially inappropriate behaviors Understanding, appreciation, reasoning, and choice Support systems Robustness TIC & MRD? Motivated Reliable Dependable What are the Obstacles to MRD?? Document and content not to be used without permission 9

10 Stress/Trauma Intensifiers Wellness Importance S E L F C A R E Uncertainty Duration Robustness & Resiliency Definitions Robustness Having strength or vigorous health Capable of performing without failure under a wide range of conditions Resiliency The ability to bounce back from life developments. When hurt & distressed, resilient people Allow themselves to feel grief, anger, loss, and confusion Don t get stuck in a permanent feeling state Robust & Resilient People Cope well with stressful events and long term strain Maintain good energy and health when under stress Bounce back stronger from setbacks Change approaches when old ways no longer work Do not react in dysfunctional or harmful ways SAMHSA s Eight Dimensions of Wellness Source: Adapted from Swarbrick, M. (2006). A wellness approach. Psychiatric Rehabilitation Journal, 29(4), Confront problems directly Document and content not to be used without permission 10

11 Success Success: Love, Life, Work & Play Define your success based on what you do, Not what someone else (customer/client) does! Informed Approaches! Thrive, Don t Just Survive! Think it through Your Relationship w/ Client Emotional Client Strengths Relax Environmental Financial Culture Mental Health &/or Substance Abuse Issues Cognitive Issues Intellectual Social Relationship Issues Other RIGHT NOW: Need or Want Physical Spiritual Client/Caregiver Rejuvenate You (paperwork, referrals, information, program expectations, etc.) Occupational Your Intention(s) & Possible Approach(es) Successful Work Strategies Successful Life Strategies Emotional Intelligence Productive Time (2 hours or less) 1 1 ½ Hour Work Periods Transition: tasks, home -work-home Meditation or Brain Breaks (5x for 5 minutes) 3:1 Positivity Group Like-Tasks Plan, Prioritize & Schedule Clients (up to min) Casework & Non-casework Do Not Disturb Time Return calls that don t require direct communication first thing in AM or last in PM near lunch time Utilize your resources - take time off! Relax & Rejuvenate! Keep an eye on your reactions; Know your personal signs and triggers Maintain professional boundaries Foster Team Resilience: positivity, trust & social connections Relax & Rejuvenate! Nutrition Exercise Sleep Emotional/Stress awareness, tolerance & management Deal with stressful & traumatic events Impulse Control Optimism (3:1) Self Regard Leave work at work (process for a short time) Take 30 minutes every day to do what you WANT to do, what touches your heart or fills you up Prioritize meditation, fun & family Be around people and do things that make you happy Recognize you are part of something bigger Prioritize & balance trade offs Hughes, M. (2014) Document and content not to be used without permission 11

12 IMPORTANCE (1-10 scale) COMMITMENT (1-10 scale) CONFIDENCE (1-10 scale) It s About Fit! Making it Real Balance = bunk! Balance over a month, maybe! Fit Values Goals Requirements Priorities Desires Schedule it! What do you know about yourself & self care? What is 1 thing you can do to care better for yourself? Recap Integration U S E I T, O R L O S E I T! Understand Stress/Trauma Understand scarcity Care well for yourself! Support healing in yourself & clients. Integration GOAL: I want to use what I learned today so that I OBJECTIVES: I will accomplish the above goal through the following steps. Please Complete an Evaluation! T H A N K Y O U! OBJECTIVES OR STEPS WHEN HOW OFTEN HOW I WILL KNOW IT S A SUCCESS WHEN I WILL EVALUATE PROGRESS BARRIERS PLAN TO OVERCOME BARRIERS Document and content not to be used without permission 12

13 References & Resources 1 References & Resources 2 Bloom, S. (2013). Creating Sanctuary, 2nd edition. Abingdon, Oxon: Routledge. Hughes, Marcia. (Presenter). (2014, January 29). Training Industry.com. Managing Your Reslience Meter: A Guide to Positivity, Productivity & Well- Being. Webinar retrieved from Levine, P.A. & Frederick, A. (1997). Waking the Tiger: Healing Trauma. North Atlantic Books. Miller, W.R. & Rollnick, S. (2012). Motivational Interviewing, Third Edition: Helping People Change. Guilford Press: New York. Ogden, P., Minton, K., Pain, C. (2006). Trauma and the Body. New York: W. W. Norton and Company. Rock, D. (2009). Your Brain at Work: Strategies for overcoming distraction, regaining focus, and working smarter all day long. New York, NY: HarperCollins. Sharp, C.S. (2014, September 22). Becoming Trauma-Informed. Relias Webinar from the National Council for Behavioral Health at Schwartz, T. (2010). The Way We Are Working Isn t Working. Free Press: New York. Siegel, D. (2010). Mindsight. Random House: New York. Siebert, A. (2005). The Resiliency Advantage. San Francisco, CA: Berrett- Koehler Publishers Inc. References & Resources 3 Shenk, D. (2010). The Genius in All of Us. Doubleday: New York. Substance Abuse and Mental Health Services Administration (SAMHSA). (2014). Trauma-Informed Care in Behavioral Health Services. Treatment Improvement Protocol (TIP) Series 57. HHS Publication No. (SMA) Rockville, MD: SAMHSA. Retrieved from Substance Abuse and Mental Health Services Administration (SAMHSA). (2005). A Guide to Managing Stress in Crisis Response Professions. DHHS Publication No. (SMA) Rockville, MD: SAMHSA. Retrieved from Document and content not to be used without permission 13