1 B Ron Luce, President Ohio Recovery Housing Kim Kehl, TIC Project Coordinator OhioMHAS
2 All behavior has meaning and purpose Symptoms are ADAPTATIONS Responses should be about comfort not control We build on success not deficits
3 Science of Trauma New lens through which to understand the human story Preserve safety Why we suffer How we parent, raise and mentor our children How we treat, support and empower a person toward personal wellness How we might better prevent, treat and manage illness in our medical care systems How we can recover and heal on deeper levels How we acknowledge a hurt that must be healed
Things to remember Underlying question = What happened to you? Symptoms = Adaptations to traumatic events Healing happens In relationships
5 What is Trauma? Trauma results from an Event or a series of events or set of circumstances that is Experienced by an individual as physically and/or emotionally harmful or life threatening, and which has lasting adverse Effects on the individual's functioning or physical, social, emotional and spiritual well-being. (December 2012)
6 What is Trauma? The Three E s Events Experience Effects Events/circumstanc es cause trauma. An individual s experience of the event determines whether it is traumatic. Effects of trauma include adverse physical, social, emotional, or spiritual consequences.
7 Traumatic Events: (1) render victims helpless by overwhelming force; (2) involve threats to life or bodily integrity, or close personal encounter with violence and death; (3) disrupt a sense of control, connection and meaning; (4) confront human beings with the extremities of helplessness and terror; and (5) evoke the responses of catastrophe. (Judy Herman, Trauma and Recovery, (1992)
Adverse Childhood Experiences Study 8 Collaboration between Kaiser Permanente and CDC 17,000 patients undergoing physical exam provided detailed information about childhood experiences of abuse, neglect and family dysfunction (1995-1997) The ACE study indicates: Adverse childhood experiences are the most basic and long-lasting cause of health risk behaviors, mental illness, social malfunction, disease, disability, death, and healthcare costs
9 ACEs /Separation
10 ACE Score and Health Risk As the ACE score increases, risk for these health problems increases in a strong and graded fashion:
Adverse Childhood Experiences are Common 11 Of the 17,000 HMO Members: 1 in 4 exposed to 2 categories of ACEs 1 in 16 was exposed to 4 categories. 22% were sexually abused as children. 66% of the women experienced abuse, violence or family strife in childhood.
What are some other examples of potential traumatic events? 12
13 ACE Score and Health Risk As the ACE score increases, risk for these health problems increases in a strong and graded Alcoholism and fashion: alcohol abuse Chronic obstructive pulmonary disease (COPD) Depression Hallucinations Fetal death 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
14 The ACE Comprehensive Chart Adverse Childhood Experiences Neurobiological Impacts and Health Risks Long-term Health and Social Problems The more types of adverse childhood experiences The greater the neurobiological impacts and health risks, and The more serious the lifelong consequences to health and wellbeing
Prevalence of Trauma Substance Abuse Population 15
16 Prevalence of trauma NIDA suggests that up to two thirds of individuals with substance use disorders have experienced trauma Rape victims are three times as likely to use marijuana, six time mores likely to have used cocaine and ten times as likely to have used other drugs, including heroin and amphetamines The National Institute on Drug Abuse (NIDA) - 2015
Trauma in adults substance abuse 17 Of persons with diagnosed substance abuse disorders: 71.6 percent of the sample reported witnessing trauma 30.7 percent experienced a trauma that resulted in injury, and 17.3 percent experienced psychological trauma The Substance Abuse and Mental Health Services Administration (SAMHSA) - 2015
18 A male child with an ACE score of 6 has a 4,600% increase in likelihood of later becoming an IV drug user when compared to a male child with an ACE score of 0. Might drugs be used for the relief of profound anguish dating back to childhood experiences? Might it be the best coping device that an individual can find? (Felitti, 1998)
19 Is drug abuse self-destructive or is it a desperate attempt at self-healing, albeit while accepting a significant future risk? (Felitti, 1998) Basic cause of addiction is experience-dependent, not substance-dependent Significant implications for medical practice and treatment programs
20 Trauma in adults mental health 61 percent of men and 51 percent of women with a mental health issue reported experiencing at least one trauma in their lifetime with witnessing a trauma being involved in a natural disaster and/or experiencing a life-threatening accident ranking as the most common events The Substance Abuse and Mental Health Services Administration (SAMHSA) - 2015
21 Trauma in Adults: Mental Health Clients with histories of childhood abuse Earlier first admissions More frequent and longer hospital stays More time in seclusion or restraint Greater likelihood of self-injury or suicide attempt More medication use More severe symptoms (Read et al, 2005) The Substance Abuse and Mental Health Services Administration (SAMHSA) - 2015
22 Trauma in Veterans Those with military experience had greater odds of any difference in prevalence of ACEs Enlistment may serve as an escape from adversity for some individuals, at least for men The impact of deployment and reintegration are significant for children of active duty members Adults with exposure to one or more lifetime potentially traumatic events (PTEs) were more likely to be older, to not be Hispanic/Latino white, to be veterans or to have certain health conditions
23 Trauma in Veterans Among Vietnam veterans, approximately 15% of men and 9% of women were found to have PTSD at the time of the study; approximately 30% of men and 27% of women had PTSD at some point in their life following Vietnam Persian Gulf War veterans have found that rates of PTSD stemming from the war range anywhere from almost 9% to approximately 24% In one major study of Iraq and Afghanistan soldiers found combat-related situations, such as being attacked or ambushed (92%), seeking dead bodies (94.5%), being shot at (95%), and/or knowing someone who was seriously injured or killed (86.5%) After deployment, approximately 12.5% had PTSD, a rate greater than that found among these soldiers before deployment.
Trauma in the homeless population The prevalence of traumatic stress in the lives of persons and families experiencing homelessness is extraordinarily high. A study from 2005 on the need for abuse and trauma services among people experiencing homelessness reported that 69% of men who had co-occurring disorders had experienced a lifealtering traumatic event. In the 2010 SHIFT Study, 93 percent of mothers had a history of trauma, and 81 percent had experienced multiple traumas.
Risk Factors for Homelessness & ACEs Health Care for the Homeless Clinicians Network 2008 Risk Factor Histories of foster, group and institutional care ACE Childhood physical, emotional and sexual abuse Neglect in childhood ACE ACE Substance abuse in the family Homelessness in the family of origin High use of inpatient psychiatric and medical services Low levels of education Substance abuse Mental Illness
What other groups of people that you work or interact with might experience trauma and why? 26
Emotional Problems 27
28 Childhood Experiences Underlie Chronic Depression
29 Childhood Experiences Underlie Suicide 4+ 3 0 1 2
30 2/3 rd (67%) of all suicide attempts 64% of adult suicide attempts 80% of child/adolescent suicide attempts Are Attributable to Childhood Adverse Experiences Women are 3 times as likely as men to attempt suicide Men are 4 times as likely as women to complete suicide
31 Ever Hallucinated* (%) ACE Score and Hallucinations ACE Score *Adjusted for age, sex, race, and education.
32 Percent With Memory Impairment (%) ACE Score and Impaired Memory of Childhood ACE Score 1 2 3 4 5 ACE Score
Health Risk Behaviors 33
34 Adverse Childhood Experiences and Current Smoking %
35 Childhood Experiences and Adult Alcoholism 4+ 2 3 1 0
Serious Social Problems 36
Childhood Experiences Underlie Rape 4+ 2 3 1 0
ACEs Underlie Domestic Violence 38 Women with ACE Score of 4+ are 500% more likely to become victims of domestic violence. Both men and women are more likely to become perpetrators of domestic violence
Adverse Childhood Experiences and Likelihood of > 50 Sexual Partners 41
ACE Score and Unintended Pregnancy or Elective Abortion
43 Adverse Childhood Experiences and History of STD
44 Sexual Abuse of Male Children and Their Likelihood of Impregnating a Teenage Girl 35 30 25 1.3x 1.4x 1.8x 20 1.0 ref 15 10 5 0 Not 16-18yrs 11-15 yrs <=10 yrs abused Age when first abused
45 Prevalence of Impaired Performance (%) ACE Score and Indicators of Impaired Worker Performance 25 20 ACE Score 0 1 2 3 4 or more 15 10 5 0 Absenteeism (>2 days/month Serious Financial Poblems Serious Job Problems
46 TRAUMA SYMPTOMS = TENSION REDUCING BEHAVIORS How do I understand this person? rather than How do I understand this problem or symptom?
47 Adaptive Responses When Overwhelmed Agitation Hypervigilence Hopelessness Insomnia Intrusive Memories Nightmares Shame & Self Hatred Numbing Depression Traumatic Event Somatic Symptoms Dissociation Self Destructive Behavior Generalized Anxiety Panic Attacks Substance Abuse Eating Disorders
48 The Four R s A trauma-informed program, organization, or system: Realizes Realizes widespread impact of trauma and understands potential paths for recovery Recognizes Recognizes signs and symptoms of trauma in clients, families, staff, and others involved with the system Responds Responds by fully integrating knowledge about trauma into policies, procedures, and practices Resists Seeks to actively Resist re-traumatization.
49 Core Principles Safety Trustworthiness and transparency Collaboration and mutuality Peer Support and Mutual Self-Help Empowerment, Voice and Choice Cultural, Historical and Gender Issues Resilience and Strengths Based: Belief in resilience and the ability of individuals, organizations and communities to heal and recover Promote recovery from trauma Builds on what clients, staff and communities have to offer rather than responding to perceived deficits
PRINCIPLE 1: SAFETY 50 Throughout the organization, staff and the people they serve, feel physically and psychologically safe. Do personal interactions promote a sense of safety? How do persons served define safety? What changes need to be made to address safety concerns? Does the organization work on risk management principles or is the organization risk averse?
PRINCIPLE 2: TRUSTWORTHINESS AND TRANSPARENCY 51 Operations and decisions are conducted with transparency and the goal of building and maintaining trust among clients, family members, staff, and others involved with the organization. Is the organization constantly building trust? Do people really understand their options?
PRINCIPLE 3: PEER SUPPORT 52 Key to establishing safety and hope, building trust, enhancing collaboration, serving as models of recovery and healing, and maximizing a sense of empowerment. Does the organization practice principles of peer support? Is there peer support for staff? Are the staff prepared to accept peer supporters?
PRINCIPLE 4: COLLABORATION AND MUTUALITY 53 Partnering and leveling of power differences between staff and clients and among organizational staff Demonstrates that healing happens in relationships, and in the meaningful sharing of power and decision-making Everyone has a role to play; one does not have to be a therapist to be therapeutic Is there true partnership between people served and staff and between management and staff?
PRINCIPLE 5: EMPOWERMENT, VOICE, AND CHOICE 54 Individuals strengths and experiences are recognized and built upon The organization fosters a belief in resilience Clients are supported in developing self-advocacy skill and self-empowerment How are successes celebrated in the organization?
55 PRINCIPLE 6: CULTURAL, HISTORICAL, AND GENDER ISSUES The organization actively moves past cultural stereotypes and biases Offers gender-responsive services Leverages the healing value of traditional cultural connections Recognizes and addresses historical trauma
56 Outcomes with TIC Improved quality of care and impact of care Improved safety for consumers, families and staff Decreased use of emergency rooms Fewer no-shows to appointments Improved consumer engagement Improved consumer satisfaction Improved staff satisfaction Decreased burnout and staff turnover Highlights glitches in the systems and offers solutions Works with other best practices
57 SAMHSA s Definition of Recovery Recovery is a process of change through which individuals improve their health and wellness, live a selfdirected life, and strive to reach their full potential.
58 What we CAN do... Show genuine concern and be sensitive to physical or intellectual barriers, gender and cultural issues. Understand that troubling behaviors that we may find uncomfortable likely helped the person cope/survive under extreme circumstances. Seek to understand their experiences and identify a path to healing. Help link the person with trauma responsive services and ensure continuity of care between organizations and across systems. Ask What happened to you? instead of What s wrong with you?
59 What we CAN do... Treat everyone with universal precaution: Assume that the person has experienced trauma even if you don t know their personal history. Create a welcoming environment that promotes a feeling of safety and non-violence pay attention to physical space, tone of voice, loudness of music or side conversations and eliminate anything that could be intimidating or anxiety provoking. Be very aware of personal space. Realize that some painful memories may be triggered by touching, hugging, behaving authoritatively, standing over the person or blocking their exit in a closed space, etc.
60 What we CAN do... Recognize that certain practices (e.g., seclusion and restraint) may create trauma and trigger traumatic memories. Make a commitment to non-violence in words, actions and policy/practices. Support meaningful power-sharing and decision-making Voice and Choice! Use tools/approaches that help calm fear/anxiety/anger/defensiveness as a preventative and healing method rather than engaging in confrontational approaches that focus on coercion or control of external behavior.
61 Putting it all together First ask, What happened to you? Then, support a survivor, in 4 difficult sentences: 1. I believe you. 2. Thank you for trusting me enough to tell me. 3. I am sorry that happened to you. 4. I support you whatever you choose to do. Then, listen and be present. And then, listen and be present some more. You ll experience an urge to take care of the person. That s normal, because you care. But you must, must, must sit still with it and let the person take care of herself or himself. Trauma is (in part) about having control over your body and your choices taken away. Survivors need safe environments where they can take back control. Sit still, notice that you care, be kind to yourself, and sit still some more. You have given the greatest gift you can give; yourself. Your caring attention. And then go take really good care of yourself!
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TIC: Why is this important? 64
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WHAT HELPS 66
67 Only in the presence of compassion will people allow themselves to see the truth. ~ A.H. Almaas
68 "We have this incredible proof about the expense that trauma is causing our society and how all of these physical ailments are related. And yet, what do you do to change it? It s not like, Well, eat more broccoli. Patricia Wilcox, head of the Traumatic Stress Institute at Klingberg Family Centers in New Britain
69 Dr. Mark Hurst, M.D., FAPA Medical Director, OhioMHAS 30 East Broad Street, 36 th Floor, Columbus, OH 43215 (614) 466-6890 Mark.Hurst@mha.ohio.gov Ron Luce President Ohio Recovery Housing (740) 517-8647 ron@ohiorecoveryhousing.org Tina Evans Regional Liaison Team Lead, Division of Policy & Strategic Direction 30 East Broad Street, 12 th Floor 614-752-09028 tina.evans@dodd.ohio.gov Kim Kehl TIC Project Coordinator, Office of the Medical Director OhioMHAS 30 East Broad Street, 36 th Floor, Columbus., OH 43215 (614) 644-8442 Kim.kehl@mha.ohio.gov