Trauma Informed Approach. Objectives 3/7/2018. Understanding Trauma: How Come?

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1 Trauma Informed Approach Heather Phelps, MA, LPC, Criminal Justice Planner Patrick Sidmore, MSW, Health Planner Objectives Relationship between childhood trauma and brain development/stress response ACES and Alaska population Self-regulation Recognize the impact of trauma with the criminal justice population Understanding Trauma: How Come? Current problems may be related to traumatic life experiences Understanding trauma can aid in providing more effective services Current behaviors can be triggered by traumatic life experiences which shape how person interacts with environment SAMHSA It s Just Good Medicine: Trauma Informed Primary Care

2 Trauma, Coping and Survival People who live with long term abuse will figure out how to avoid getting hurt Substance use, Defensiveness aggression/violence These coping mechanisms can lead to legal involvement How Being Trauma Informed Improves Criminal Justice System Responses Version 3.1 Benefits of Trauma Informed Approach Awareness that trauma from early life may contribute to ongoing criminal justice involvement Through understanding trauma, develop trauma informed responses Increase safety Decrease recidivism Promote recovery The Brain 6 2

3 Abstract thought Planning for future Decision-making Self-awareness & insight Balancing emotions Empathy Memory Attention Emotions Motor Regulation Sleep Digestion Staying alive respiration, heart rate Slide Courtesy of Linda Chamberlain, Ph.D. Building Blocks of the Brain Peter Camburn Wired Up Wired Down 8 What is stress? The set of changes in the body and the brain that are set into motion when there are overwhelming threats to physical or psychological well-being. When we are threatened the body activates physiological responses including increases in heart rate, blood pressure, and production of stress hormones such as cortisol (From Neurons to Neighborhoods, National Research Council and Institute of Medicine, 2000) Slide Courtesy of Shirley Pittz 9 3

4 Learning how to cope with adversity is important part of healthy development Homeostasis Stability Balance Slide Courtesy of Shirley Pittz 10 It was kinda weird and.. nervous Positive Stressmoderate, short-lived stress responses, such as brief increases in heart rate or mild changes in stress hormone levels Slide Courtesy of Shirley Pittz Tolerable Stress- could disrupt brain architecture but is buffered by supportive relationships that facilitate adaptive coping Slide Courtesy of Shirley Pittz 12 4

5 Toxic Stress- strong and prolonged activation of the body s stress management systems in the absences of the buffering protection of adult support Slide Courtesy of Shirley Pittz 13 Josh Arvidson 14 Josh Arvidson 15 5

6 Josh Arvidson 16 What does it look like? Centers for Disease Control and Prevention 17 Dan Siegal Clip 4Oxw 6

7 Adverse Childhood Experiences What are they? Physical abuse/neglect Emotional abuse/neglect Sexual abuse An alcohol and/or drug abuser in the household Incarcerated household member Household Mental Illness Mother is treated violently Parental Separation/Divorce Adverse Childhood Experiences Are Common Household dysfunction: Substance abuse 27% Parental separation/divorce 23% Mental illness 17% Battered mother 13% Criminal behavior 6% Abuse: Psychological 11% Physical 28% Sexual 21% Neglect: Emotional 15% Physical 10% Source: Robert F. Anda, MD, MS, Co-Principal Investigator, 7

8 Adverse Childhood Experiences Score Complex Trauma--Trauma Dose ACE Score Number of individual types of adverse childhood experiences were summed Prevalence 0 33% 1 26% 2 16% 3 10% 4 or more 16% Source: Robert F. Anda, MD, MS, Co-Principal Investigator, Percentage of Alaskan Adults who Reported Individual ACEs by Type Emotional Neglect 15.8% Physical Neglect 11.1% Incarcerated Family Member 11.2% Separation or Divorce 31.8% Witnessed Domestic Violence 18.6% Household Substance Abuse 34.0% Household Mental Illness 21.3% Emotional Abuse 32.7% Sexual Abuse 15.9% Physical Abuse 18.3% 0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0% 35.0% 40.0% Sources: Alaska BRFSS, Section of Chronic Disease Prevention and Health Promotion, Alaska Division of Public Health, & Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System Survey ACE Module Data, 2010 ACE and Alaska More than 11% of Alaskan adults report growing up in a household where someone they lived with was incarcerated More than one third of AK adults report growing up in household where substance abuse was present In Alaska, we spend 1.2 billon on substance abuse, research suggests that 246 million of this is linked to ACEs DHSS.Alaska.gov/abada/aceak/pages/default.aspx 8

9 Cumulative risk 10% During 2015 in Alaska, nearly 7,700 children ages 0-6 years experienced a report for maltreatment 9% 18% 25% 31% Among children born in 2009:2011, nearly 10,241 were reported for maltreatment before age 7 <1 <3 <5 <7 Life Course (age in years) 26 Ten State and DC - ACE Results The prevalence estimates reported are from Washington, DC and ten states (HAWAII, MAINE, NEBRASKA, NEVADA, OHIO, PENNSYVANIA, UTAH, VERMONT, WASHINGTON, and WISCONSIN) who included the ACE module on the 2010 BRFSS (n=53,784) 27 9

10 Percentage Percentage 35.0% 39.3% 15.9% 18.6% 10.9% 13.7% 14.9% 18.6% 25.1% 29.7% 16.3% 21.4% 22.8% 31.6% 5.7% 11.3% Percentage of Alaskan Adults Adverse Childhood Experiences Compared to a Ten State and D.C. Sample* 45.00% 40.00% 35.00% 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% 10 State (N=53,784) Alaskan (N=10,847) Adverse Childhood Experience *In the category of Emotional Abuse the Ten State & DC Study used all positive answers (once and more than once) as a measure of indicating the presence of that ACE. This hasn t been done in other BRFSS ACE studies but in this comparison it was used with the Alaska data to provide a comparable rate between the two populations. Sources: Alaska BRFSS, Section of Chronic Disease Prevention and Health Promotion, Alaska Division of Public Health, Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System Survey ACE Module Data, % ACE Scores for Alaskan Adults and The Ten State and DC Sample 40.0% 40.7% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 34.3% 23.6% 22.2% 24.1% 21.4% 14.3% 19.5% 10 States & DC Total (N =53,784) Alaskan Total Percent (N =10,847) 5.0% 0.0% Zero One Two-Three Four or More ACE Score Sources: Alaska BRFSS, Section of Chronic Disease Prevention and Health Promotion, Alaska Division of Public Health, & Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System Survey ACE Module Data, 2010 Population Attributable Fraction Source: Alaska BRFSS, Section of Chronic Disease Prevention and Health Promotion, Alaska Division of Public Health, Graphic by Alaska Mental Health Board Staff 30 10

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12 Population Attributable Fraction Source: Child and Adolescent Health Management Initiative (2012) National Survey of Children s Health (2012), U.S. Department of Health and Human Services, Health Resources and Services Administration. Graphics and analysis done by the Alaska Mental Health Board and Advisory Board on Alcoholism and Drug Abuse Staff Trauma Prevalence Research in Corrections Trust Beneficiaries 12

13 Understanding Trauma: How Come? "There are high levels of trauma in both men and women, and in justice-involved individuals. Based on these statistics, it is safe to assume that everyone who comes into contact with the justice system has a history of trauma, so criminal justice professionals should take 'universal precautions'." SAMHSA Trauma Prevalence Studies Jail Diversion Study Women 96% lifetime Women 74% current Men 89% lifetime Men 86% current Mental Health Court Study Women 67% child physical abuse Women 34% current physical/sexual abuse Men 73% child physical abuse Men 32% current physical/sexual abuse Trauma Prevalence Studies Trauma Experiences with Incarcerated Persons study Physical trauma as child 44.7% Physical trauma as adult 31.5% Sexual trauma as child 10.9% Sexual trauma as adult 4.5% 13

14 Trust Beneficiaries and ADOC Involvement Prevalence Accounts for 40% incarcerations per year Length The median length of stay is significantly longer for TB, for felonies double and for misdemeanors, 150% longer Recidivism Nearly double (40.9% vs. 22.0%) Increase odds of recidivism in first year by 44% Trust Beneficiaries in Alaska s DOC 2014 Hornby Zeller Assoc Inc Trust Beneficiaries & State Agency Involvement OCS One third have been involved with OCS Higher rate of recidivating first year released 35.5% vs 27.8% DJJ Nearly a quarter have a juvenile justice history Higher recidivism rate 48.8% vs 38.0% Trust Beneficiaries in Alaska s DOC 2014 Hornby Zeller Assoc Inc What This Means ADOC is handling an inmate population which two thirds have a mental health disorder, SUD, or cognitive impairment Trust beneficiaries are generally incarcerated for longer periods of time and are arrested more often Trust Beneficiaries in Alaska s DOC 2014 Hornby Zeller Assoc Inc 14

15 Long Term Effects Never feeling safe Feelings of powerlessness Anger that can become uncontrolled Overwhelming emotional pain Physical health Mental health Behavioral Relationships Substance use How Being Trauma Informed Improves Criminal Justice System Responses Version 3.1 Mental Health and Trauma Trauma Mental Illness Trauma may exacerbate mental illness How Being Trauma Informed Improves Criminal Justice System Responses Version 3.1 Trust Recommendations Provide training to all correctional staff, both community based and facility, on traumainformed correctional practices and expand the use of trauma specific programming to encompass all facilities with mental health and substance abuse units. ADOC has implemented Seeking Safety in a few facilities and the Trust recommend that this program or a similar program be provided to all facilities with a mental health unit once or twice a year. Trust Beneficiaries in Alaska s DOC 2014 Hornby Zeller Assoc Inc 15

16 Self-Regulation Finishes tasks and follows through on commitments 2. Stays calm and in control when facing a challenge 3. Shows interest and curiosity in learning new things Source: Child and Adolescent Health Management Initiative (2012) National Survey of Children s Health (2012), U.S. Department of Health and Human Services, Health Resources and Services Administration. Graphics and analysis done by the Alaska Mental Health Board and Advisory Board on Alcoholism and Drug Abuse Staff 47 Source: Child and Adolescent Health Management Initiative (2012) National Survey of Children s Health (2012), U.S. Department of Health and Human Services, Health Resources and Services Administration. Graphics and analysis done by the Alaska Mental Health Board and Advisory Board on Alcoholism and Drug Abuse Staff 48 16

17 Murray, Desiree W., Rosanbalm, Katie, Christopoulos, Christina, and Hamoudi, Amar (2015). Self- Regulation and Toxic Stress: Foundations for Understanding Self- Regulation from an Applied Developmental Perspective. OPRE Report # , Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services. 49 SEVEN KEY PRINCIPLES OF SELF-REGULATION SELF-REGULATION: serves as the foundation for lifelong functioning is defined from an applied perspective as the act of managing cognition and emotion enactment is influenced by a combination of individual and external factors can be strengthened and taught is dependent on co-regulation provided by parents or other caregiving adults can be disrupted by prolonged or pronounced stress and adversity including poverty and trauma experiences develops over an extended period from birth through young adulthood and beyond Murray, Desiree W., Rosanbalm, Katie, Christopoulos, Christina, and Hamoudi, Amar (2015). Self- Regulation and Toxic Stress: Foundations for Understanding Self- Regulation from an Applied Developmental Perspective. OPRE Report # , Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services. 50 Self-regulation can be strengthened and taught, with focused attention, support, and practice opportunities provided across contexts. Skills that are not developed early on can be acquired later, with multiple opportunities for intervention. Murray, Desiree W., Rosanbalm, Katie, Christopoulos, Christina, and Hamoudi, Amar (2015). Self- Regulation and Toxic Stress: Foundations for Understanding Self- Regulation from an Applied Developmental Perspective. OPRE Report # , Washington, DC: Office of Planning, Research and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services

18 Self-Regulation and Criminal Justice Improving executive functions Improving effortful control Teaching behavior change skills Improving non-conscious self-regulation Current Issues in Self Regulation Research and their Significance for Therapeutic Intervention in Offender Groups--Thomas Ross 2007 Trauma Informed Approaches While in Custody and in Reentry Remember High levels of trauma found in justice involved individuals Safe to assume that everyone who comes into contact with the justice system has a history of trauma Universal precautions SAMHSA 18

19 Trauma Definition Event Single Recurring Set of circumstances Experience Terrifying Threatening Overwhelming Feelings of fear, horror, helplessness, anger, guilt, shame, betrayal Effect Reshapes world view Self Beliefs Relationships How Being Trauma Informed Improves Criminal Justice System Responses Version 3.1 Trauma Effects Affects broad aspects of life Behavior can be coping or for survival Can lead to justice involvement How Being Trauma Informed Improves Criminal Justice System Responses Version 3.1 Trauma Informed Approach Realizes Widespread impact of trauma and understands potential paths for recovery Recognizes Signs and symptoms of trauma in clients, families, staff, and others involved with the system Responds Fully integrates knowledge about trauma into policies, procedures, and practices re-traumatization Seeks to actively resist retraumatization SAMHSA NCTIC 19

20 Men, Trauma, and Prison Male inmates have the risk of being threatened, pressured, or forced into sex The possibility of witnessing another inmate being sexually assaulted increases Threat of violence, physical assault increases Prison = less safe from sexual assault RSAT Training Tool: Trauma Informed Approaches in Correctional Settings 2011 Women, Trauma, and Prison Women may be safer in prison than in the community Higher risk for anger and hostility which can lead to behavioral problems Sexual abuse hx may more likely be triggered and have symptoms of disorientation and disconnection Emotional numbing, dissociation, hyper responsiveness may make it more difficult to adjust to prison Miller and Najavits 2012 Corrections Trauma Authority, not being in control Being assaulted (physical/sexual) Witness self mutilation Loud noises Strip search, restraints Unexpected family death Listening to inmates describe their own traumatic experiences Witness & responding to violence among inmates Witness & responding to violence directed at staff Restricted freedom Discovering dead body Suicide of fellow inmate Threats by other inmates Hearing what other inmates did to their victims Hearing about/viewing images of staff injuries or inmate injuries 20

21 Corrections Trauma Inmate assault on staff Witness self mutilation Near misses and what could go wrong Discovering dead body Intervening suicide attempts Unexpected staff death Threats by inmates Hearing what inmates did to their victims Listening to inmates describe their own traumatic experiences Witness & responding to violence among inmates Witness & responding to violence directed at coworkers Reading graphic accounts of crimes Hearing about/viewing images of staff injuries or inmate injuries Staff Traumatic Stress Primary: Personally experience or observe an event that poses a risk to self or others Secondary: When professionals experience trauma symptoms as a result of exposure to pain and suffering of others Traumatic Stress & Correctional Officers COs may experience considerable job related stress: Greater potential for immediate violence Reduced staffing Interpersonal conflict Daily exposure to trauma stress 21

22 Traumatic Stress & Probation Officers Out of 2,256 PO, 29% said that they have experienced four or more primary traumatic events in their career Out of 2,038 PO, 22% said that they always are exposed to traumatic material daily and 29% said that they are frequently exposed to traumatic material daily. Out of 2,266 PO, 48% reported that they have experienced four or more secondary traumatic events in their career Benefits of Trauma Informed Approach Effective behavior management and services Safety Job satisfaction Promote recovery Cost of healthcare Staff turnover Restrain/seclusion Recidivism Niki Miller and Lisa Najavits Benefits of Implementing TI Approaches Type Frequency Change % Change Inmate on staff assaults % Inmate on inmate assaults % Inmate on inmate fights % Segregation % Disciplinary Reports % Suicide Attempts % 1 on 1 MH watches % Petitions for psychiatric evals % Crisis contacts % Self Injury Incidents % National Resource Center on Justice Involved Woman 2014-MCI at Framingham 22

23 Strengths of TI in Corrections Safety Highly structured environment Predictable and consistent limits, incentives, boundaries Swift and certain consequences Treated fairly and equally Provide stability which helps learning new information and skills Culture of responsibility, consistency, accountability, behavioral change Niki Miller and Lisa Najavits Challenges in TI in Corrections Designed to house perpetrators Each inmate is potentially violent Restricted freedom/movement Sensory and environmental triggers Pervasive authoritative presence Abrupt detoxification of substances Culture of mistrust Niki Miller and Lisa Najavits Taking Current Practice to TI Relationships Staff teach skill building while being aware how trauma impacts people. Staff manage own affect, read cues and respond consistently to provide safety Safety Goal to maintain safety, de-escalate, and learn from restraint TI view safety first while at the same time minimizes re-traumatization Accountability Being TI does NOT mean abandoning accountability, TI assumes that accountability is maintained 69 23

24 Preventing Retraumatization Anticipate and be sensitive to how policy, procedure in treatment may act as triggers Attend to person s experiences Develop coping skills with routine rehearsal Control or containment behavior can cause traumatic stress reactions Listen for specific triggers Avoid shaming Respond consistently Trauma Informed Care in Behavioral Health Services 2014 Some Examples Intake/admissions/screening: let inmates know what you will be asking, why, and who has access to info Assessment: train staff to recognize trauma symptoms Case planning: provide copies of plans Staff inmate interactions: use postures and body proximity that convey safety and support National Resource Center on Justice Involved Woman 2014 Some Examples Sanctions/disciplines: talk about what happened with inmates after a restraint occurred Programming: do trauma treatment only if there is sufficient time and is appropriate Medical services: medication reasons, potential side effects MH services: offer classes that describe links between trauma, substance use, and mental health National Resource Center on Justice Involved Woman

25 DOC HARS Vision Statement We are committed to the wellbeing of those under the care of the Alaska Department of Corrections. Individuals will be treated in a safe, respectful and compassionate manner. We are dedicated to providing essential care and to promoting health and rehabilitation. DOC and Trauma Informed MH staff trained in trauma informed approaches MH policy updates include more trauma informed language Mental Health First Aid training SAMHSA trauma informed approaches training DOC and Trauma Informed Suicide prevention classes address secondary trauma Rolling out additional mental health training for officers assigned to MH mods Updated electronic health record to start collecting data on abuse 25

26 DOC Facility Resources Prerelease/reentry programming Mental health services Open population Sub-Acute and Acute Mental Health Units Yoga and meditation Seeking Safety Mental Health First Aid training for inmates SUD treatment includes Exploring Trauma for Men and Healing Trauma for Women DOC Probation Resources APIC and IDP+ Probation mental health caseload Probation policies on DOC website Offender Management Plan Risk Needs Assessment-LSIR SAMHSA Trauma Informed Training How Being Trauma-Informed Improves Criminal Justice System Responses One-day training for criminal justice professionals to: Increase understanding and awareness of the impact of trauma Develop trauma-informed responses Provide strategies for developing and implementing trauma-informed policies 26

27 Trauma Informed Care for Reentry Collaborative team approach Cross training using a multiagency approach Have knowledge of trauma informed services that are available Connect with community resources that are trauma sensitive Trauma Informed Care and Reentry by David Washington Role of Community There is nothing one cannot heal from within the space of an accepting, non-judgmental community Community transforms trauma by accepting trauma survivors and supporting them in the healing process Ctacny.org 1. People Help Each Other Out 2. Watch Each Others Children 3. People to Count On 4. Adults I Can Trust Source: Child and Adolescent Health Management Initiative (2012) National Survey of Children s Health (2012), U.S. Department of Health and Human Services, Health Resources and Services Administration. Graphics and analysis done by the Alaska Mental Health Board and Advisory Board on Alcoholism and Drug Abuse Staff 81 27

28 Source: Child and Adolescent Health Management Initiative (2012) National Survey of Children s Health (2012), U.S. Department of Health and Human Services, Health Resources and Services Administration. Graphics and analysis done by the Alaska Mental Health Board and Advisory Board on Alcoholism and Drug Abuse Staff 82 Transitioning to Community Assess clinical and social needs and public safety risk Plan for treatment and services required to address individual s needs, both in custody and reentry Identify required community and correctional programs responsible for post release services Coordinate the transition plan to ensure implementation and avoid gaps in care with community based services Guidelines for Successful Transition of People with Mental or Substance Use Disorders from Jail and Prison SAMHSA 2017 Transitioning to Community Develop MOA between agencies Screen for benefits Designate resources know what is available Develop correctional and community partnerships Share information (the most basic and hardest to do) Guidelines for the Successful Transition of People with Behavioral Health Disorders from Jail and Prison SAMHSA

29 Some Examples Supporting adherence to treatment plans and supervision conditions through coordinated strategies Promoting direct linkages for post release treatment (90 day prerelease plans) Using resources like reentry coalitions Cross training in trauma informed approaches to facilitate collaboration and understanding Community Resources SB 91--Mandated reentry plan 90 days prior to release Partners Reentry Center Reentry Coalitions Alaska Resilience Initiative Alaska Child Trauma Center Summary Being aware that trauma from early life may contribute to ongoing criminal justice involvement Through understanding trauma, can develop trauma informed responses which can Increase safety Decrease recidivism Promote recovery 29