An Introduction to Trauma Informed Care in IDT KATARINA HALLONBLAD, MS, OTR/L CARMARTHEN SWIFT, MSW, LICSW MERCYLIFE PACE WEST SPRINGFIELD, MA
Trauma: Definition An event or situation that overwhelms the individual s ability to cope (Allen. J. as cited in Giller, E. (1999) It is the individual s belief or perception that they are in danger that matters (Haven, T. 2016) Overwhelming emotion and a feeling of utter helplessness (Haven, T. 2016) There may or may not be bodily injury as a result of the event (Giller, 1999)
Experiences that may be traumatic Single Events: natural disasters crimes (robbery, murder, sexual assault) surgeries deaths witnessing or directly experiencing violence Chronic or repetitive experiences : Abuse by caregiver Caregiver neglect or denial of basic needs Combat Environmental violence (gang violence, community violence, war/conflict) Concentration camps, genocide Experiencing or witnessing domestic abuse Enduring deprivation Poverty Divorce and separation from a caregiver
Trauma is Subjective and individual (up to the perception of the individual) More likely to cause lasting harm when it is repetitive and relational in nature
Damaging Effects of Trauma Experiences more likely to cause serious psychological harm: Experienced early in life Result from abuse or neglect from a caregiver and/or someone the individual feels attached to Happen over a longer period time and more than once Are unpredictable in nature The individual has limited or insufficient protective factors (family or nonfamily supports, education, socio-economic status, etc.) Are purposeful or intended to cause harm on the part of the person inflicting pain/suffering
Post Traumatic Stress Disorder (PTSD) DSM-V Diagnostic Criteria (abbreviated) Section A Exposure to potentially traumatic event(s) Section B Persistent re-experiencing of the event (flashbacks, nightmares, intrusive thoughts) Section C Avoidance of potential triggers Section D Negative thoughts/feelings that began or worsened following the event. Section E Arousal and reactivity that began/worsened after the event (irritability, heightened startle response, difficulty sleeping, etc.) Symptoms last for more than 1 month, create distress or functional impairment, and are not explained by medication or injury. (American Psychiatric Association, 2013)
Diagnosis vs Experience Many adults have experienced traumatic events early or later in life but do not meet diagnostic criteria for PTSD Trauma experienced early in life impacts individuals differently than trauma experienced later it affects how the brain develops
Window of Tolerance (Siegel, 1999)
Effects of Extreme Stress CDC
Chronic Exposure to Extreme Stress Natural alarm system no longer functions as it should. Affects ability to sense safety. Can diminish ability to trust others. Results in emotional numbing and avoidance. (Hopper, 2009)
Impact of Neglect Normal Extreme neglect (Perry, 2010)
Early Trauma Long Term Effects Individuals who experienced trauma before the age of 25 may: Develop an expectation that bad things will happen to them Have a hard time forming relationships with other people Have difficulty managing or regulating feelings and behaviors Have difficulty developing a positive sense of themselves (Blaustein and Kinniburgh, 2010)
Behavior as Means of Getting Needs Met Human beings are driven for connection and survival When basic needs are not met, we develop survival strategies (behaviors) At the time, these strategies often make sense in context. Later they may seem dysfunctional.
Adaptive Strategies Adaptive behaviors that develop during childhood and persist into adulthood may be interpreted as symptoms Trouble calming oneself gets labelled agitation Difficulty seeing the world as a safe place looks like paranoia Difficulty trusting others is seen as paranoia (even when based on experience) Disorganized thinking is labelled psychosis Expecting or allowing exploitation is called self-sabotage (Giller, 1999)
Tools for Survival Early trauma limits development of coping skills. Without effective tools to manage, individuals may learn to: Over control or shut down emotions Manage feelings through arousal behaviors (verbal or physical aggression) Manage feelings through overtly dangerous behaviors (substance use, self-injury) (Blaustein and Kinniburgh, 2010)
Protective Factors Supportive family environment Nurturing parenting skills Stable family relationships Household rules and monitoring of the child Access to health care and social services Caring adults outside family who can serve as role models or mentors Communities that support parents and take responsibility for preventing abuse Parental employment Adequate housing (Trauma Survivors Network, 2017)
ACE Study ACE = Adverse Childhood Experience Joint project of Kaiser & CDC 17,000 HMO patients studied to examine relationship between childhood stress and life long health Average age of respondents: 51 2/3 report at least one ACE 20% report 3 or more ACEs (Felitti, Anda et al., 1998)
ACE and Health Graded dose-response between ACEs and negative health outcomes 4 or more ACEs: Severe obesity (1.6 times more likely) Depression (4.6 times more likely) Alcoholism (7.4 times more likely ) Heart disease (2.2 times more likely) Any cancer (1.9 times more likely) Stroke (2.4 times more likely ) COPD (3.9 times more likely) Diabetes (1.6 times more likely) ) (Child Welfare Information Gateway, 2013)
ACEACE Conclusion Adverse childhood experiences are the most basic cause of health risk behaviors, morbidity, disability, mortality, and healthcare costs. (Felitti & Anda, 2007)
Finding your ACE score Self Assessment: http://acestudy.org/the-ace-score.html
Why does this matter to PACE? Trauma is common A history of traumatic experiences predisposes a person to a multitude of health, psychological, and substance use disorders. Many of the people we label difficult may actually be in need of a different approach. PACE organizations are holistic and person-centered so uniquely suited to address the long term effects of trauma.
Trauma-Informed Care You are not defective You are an injured person Your injuries are seen & understood Your efforts to cope are valued and validated You deserve compassion & care (Helling, 2017)
Trauma and IDT If a ppt cannot accept or receive good care, we tend to find fault in them (label, dismiss, stigmatize). Recognize risk of re-traumatization Am I attuned to the needs of this ppt as a traumatized person? How to read the signs of working relationship breaking down? How to re-organize care so that the ppt can benefit from it? Responsibility to change belongs to the provider/team
TIC Principles SAMHSA s six key principles of a trauma-informed care: Safety Trustworthiness and transparency Peer support and mutual self-help Collaboration and mutuality Empowerment, voice, and choice Cultural, historical, and gender issues (SAMHSA s Trauma and Justice Strategic Initiative, 2014)
Trauma-Informed Care Strength-based vs symptom-based Person-centered vs administration-centered Cultivating capacities vs fixing problems Participant empowering vs expert oriented Eliciting collaboration vs coercive or manipulating (Helling, 2017)
What Can You Do? Strategies for care providers: Ask permission Provide predictability and choice (even a limited set of choices) Identify strengths and use them to support success Remain calm and non-judgmental Use Active Listening - Listen more than you speak Practice self-care and self-reflection Instead of asking What is wrong with you?" ask What happened to you?" Look for the need being met through the behavior Be aware of potential triggers for behaviors and develop strategies for minimizing exposure and support (Davis, R.; Maul, A.; Center for Health Care Strategies, Inc; March 2015)
Attunement Attunement requires a curiosity and willingness to understand. Be more concerned with being caring than being right. People don't solve problems when they are afraid or enraged. The time to solve the problem or analyze is not while the person is triggered. Look for the feelings underneath the behavior.
Attunement and Curiosity Curiosity is key: think why? What is this person feeling? Is it possible this behavior is an attempt to cope in some way? Imagine this person is in incredible pain, might you respond differently?
but RESISTANCE: I want to get RESISTANCE: I want to get better, but Change can be costly Change is full of uncertainty Winning means losing Resistance is typically fear or shame-based Change can disrupt existing patterns & relationships Resistance has a purpose (Steele & Ogden, 2006)
Self-Care and Compassion Fatigue The first step to being a responsive and attuned helper is being attuned to your own needs. A regular self-care routine is necessary Working with people who have experienced trauma can be emotionally draining and leave you feeling helpless at times. Remember that the person you are trying to help may be in incredible pain. Don t take it personally. Having awareness about your own triggers can help you seek appropriate support and set personal boundaries.
Assessing your own level of stress Professional Quality of Life Scale http://www.wendtcenter.org/wpcontent/uploads/proqol_5_english.pdf Life Stress Test http://www.compassionfatigue.org/pages/lifestresstest.pdf
Progress towards TIC at MercyLIFE Book club: The Body Keeps the Score (Van der Kolk, 2014) Small committee to discuss how to implement TIC practices in MercyLIFE Consulted with an expert in TIC Webinar in TIC for all interested staff Ongoing re-framing in team discussions about ppts Presentation at Western Mass Elder-Care Conference Presentation at NPA Plan: All-staff training on staff development day
Case Examples
References Blaustein, M. E., & Kinniburgh, K. M. (2010). Appendix A. In Treating Traumatic Stress in Children and Adolescents (pp. 249-254). New York, NY: Guilford Press. Child Welfare Information Gateway. (2013). Long-term consequences of child abuse and neglect. Washington, DC: U.S. Department of Health and Human Services, Children s Bureau. ) Davis, R., & Maul, A. (2015). Trauma-Informed Care: Opportunities for HighNeed, High-Cost Medicaid Populations (pp. 3-8, Rep. No. 031915). Center for Health Care Strategies. Diagnostic and statistical manual of mental disorders: DSM-5. (2013). Washington, D.C.: American Psychiatric Association. Giller, E. (1999). What Is Psychological Trauma? Retrieved January 10, 2017, from https://www.sidran.org/resources/for-survivors-and-loved-ones/whatis-psychological-trauma/) Haven, T. J. (2016, Spring). Understanding and Responding to Trauma. Lecture at Westfield State University MSW Foundation Seminar, Westfield, MA
References (cont.) SAMHSA's Concept of Trauma and Guidance for a Trauma-Informed Approach (Publication No. 14-4884). (2014, July). Retrieved January 06, 2017, from Substance Abuse and Mental Health Services Administration website: http://store.samhsa.gov/shin/content/sma14-4884/sma14-4884.pdf Siegel, D. J. (1999). The developing mind: Toward a neurobiology of interpersonal experience. New York: Guilford Press. Trauma Survivors Network by American Trauma Society. (2017). Risk and Protective Factors. Retrieved January 30, 2017, from http://www.traumasurvivorsnetwork.org/traumapedias/777 Van der Kolk, B. (1989). The Compulsion to Repeat the Trauma: Re-enactment, Revictimization, and Masochism. Psychiatric Clinics of North America, 12(2), 389-411. Retrieved January 12, 2017, from http://www.cirp.org/library/psych/vanderkolk/ Van der Kolk, B. A. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma. New York: Viking