Trauma-Informed Practice A Rural Perspective Karolyn Holden, BSN, RN Director Grays Harbor County Public Health & Social Services www.nwcphp.org/hot-topics Presentation Overview Today we ll cover: A quick review of key concepts related to trauma-informed practice A little bit about us What trauma-informed practice means to me Our conceptual framework Examples of actions we have taken Reflections on successes and lessons learned Background: ACES & NEAR Science N euroscience E pigenetics Adverse Childhood Experiences R esilience Early Death Disease, disability, & social problems Death Adoption of health-risk behaviors Social, emotional, & cognitive impairment The ACE Pyramid: Disrupted neurodevelopment Adverse childhood experiences Conception 1
Questions for the Viewer? Do you use the concepts of NEAR science and ACEs in your practice? A. Daily B. Weekly C. Monthly D. Not at all Background: Unresolved Trauma & Reenactment Characteristics of Trauma- Organized Individuals Inability to integrate experience Hyper-arousal Lack of emotional regulation Too much or too little memory Misinterpretation of reality Triggers Re-enactment: Use of coping mechanisms that were developed in response to loss of safety in the past that persist and are no longer helpful The Drive to Re-enact Victim Who We Are: Grays Harbor County Historically Resource-Based Economy Pop.: ~71,000 Area: ~1900 mi. 2 Percentage of adults 18-64 with elevated ACE scores: 26% 38% 7-8% WA State Avg. Grays Harbor County 2
Who We Are: Public Health & Social Services Staff Retention (Years) Range <1 40 Average 13.5 Median 12 FTE by Staff Type Why traumainformed practice? Epiphany: a moment when you suddenly feel that you understand, or suddenly become conscious of, something that is very important to you Cambridge English Dictionary Universal Precautions, Holistically What if we operated under the assumption that anyone could be living with the effects of unresolved trauma? we considered the possibility that the problematic behavior we observe might be related to that? we used those assumptions and insights to inform how we engage people and interpret the meaning of their behavior? 3
Conceptual Framework Trauma-informed practice Avoid re-traumatization Triple focus Therapeutic relationships Improved outcomes Three Paths Client Interaction Trauma exposure is pervasive; our clients are particularly vulnerable. We re here to help, not hurt. Participating in re-enactment interferes with therapeutic relationships. Physical Environment People with trauma exposure struggle to feel safe. Anxiety may make it hard to read environmental cues. Hyperarousal may make it hard to focus and maintain a sense of control. Workplace Culture Trauma exposure is pervasive; helping professionals may be particularly vulnerable. We can t help if we re overwhelmed by our own injuries. Negative workplace culture affects the quality and efficiency of services. Chronology Study concepts and best practices Select framework Educate Board of Health Orient team Hold kick-off event Talk explicitly about behavior expectations link to previous demonstrated behavior Continue leadership development and peer support Begin to implement routine professional development 2016 2017 2018 Use routine meetings for education & discussion Develop leadership practices behind the scenes Demonstrate changing behavioral expectations 4
Client Interaction: Know the Basics ACES, developmental trauma, and toxic stress Science of resilience Understanding the why: neurobiology and epigenetics Trauma re-enactment Client Interaction: First Do No Harm First and foremost: we do not re-traumatize We defer judgment We step away from the re-enactment triangle Client Interaction: Flexible Empowerment Inflexibility is not trauma-informed Balance flexibility with appropriate boundaries Supportive vs. directive 5
Client Interaction: Translated Into Action Where does the rubber hit the road? Physical Environment: Our Approach Navigation cues Privacy Muted noise Comfortable surroundings Welcoming & attractive atmosphere Before: May I help you? After: 6
Before: Would you like to take a seat? After: Before: Waiting is easier when you re busy! After: For the grownups. 7
Need to step away? We re glad you re here! Workplace Culture: Initial Diagnosis Is your system trauma-organized? Directionless, valueless, mission-less Fragmented Disempowering Overwhelming Stuck 8
Workplace Culture: Know the Basics How will we know when we get there? Trauma Organized What s wrong with you? Authoritarian leadership Information held as power Gossip, triangulation Judgment Aggression Assumptions Trauma Informed What happened to you? Inclusive leadership Openness, transparency Direct communication Respect Assertiveness Curiosity Transformational Values: Safety, trustworthiness, choice, collaboration, and empowerment Workplace Culture: First Do No Harm Acknowledge the risks Accept vulnerability Leadership development Parallel process Workplace Culture: Flexible Empowerment Speak the unspeakable Communications skills at every level Contextualize conflict Normalize discomfort Be explicit Re-frame and re-direct 9
Workplace Culture: Translated into Action Halloween, 2017 Where does the rubber hit the road? It Looks Like We Did Some Things Right Labor-management: Concurrent overt discussion of morale Minimized defensiveness: started in neutral territory Walked before we talked and focused on behavior Used existing resources as deliberate investment If We d Known Then What We Know Now Think about scope: What is your team ready for? Think about current level of trust: How will what you say be interpreted? 10
Meaningful Change Happens at the Speed of Trust and it takes time. Questions for the Viewer? Has your organization employed any of these concepts in client interaction, physical space, or workplace culture? Please type your answer into the chat box. Questions? 11
References & Resource Links The Body Keeps the Score by Dr. Bessel Van Der Kolk http://besselvanderkolk.net/the-body-keepsthe-score.html ACES website compilation of materials and resources https://acestoohigh.com Paper Tigers https://kpjrfilms.co/paper-tigers/ Resilience https://kpjrfilms.co/resilience/ The Trauma Stewardship Institute http://traumastewardship.com/ The Trauma Institute - http://www.sanctuaryweb.com/ Hope White Paper http://thurstonthrives.org/wp-content/uploads/2016/05/hope-white-paper.pdf The Psychology of Hope - Chan Hellman: http://chanmhellman.com/ Science of Hope conference https://philanthropynw.org/events/foundation-heathy-generationsscience-hope-conference Childhood Disrupted (lay audience, specific to girls and women) - https://acestoohigh.com/2015/07/05/in-childhood-disrupted-donna-jackson-nakazawa-explains-howyour-biography-becomes-your-biology/ 12