Bridging Understanding about

Trauma Informed Care

Sponsored by the IDEA Partnership

with support of the Learning the Language Practice Group of the School Behavioral Health

Community www.sharedwork.org

www.ideapartnership.org

Moderators: Scott Bloom, LCSW-R

SBLOOM5@SCHOOLS.NYC.GOV

Sandy Schefkind, MS, OTR/LSSCHEFKIND@AOTA.ORG

IDEA Partnership National Community of Practice (CoP) on School Behavioral Health:

A network bridging mental health and education A mission of sharing work and common messages A common goal of improving outcomes for students with

disabilities

…..Multiple disciplines and perspectives represented including : National Organizations, TA Centers, State teams, Family groups, Individuals, etc

Learning Objectives

Attendees will: Gain understanding of trauma informed

care Learn about programs around the

country Hear a vignette that illustrates TIC

treatment principles Understand how communication plays

a key role in successful program implementation

4

Survey the Audience

What role or discipline do you represent?

5

Reflective Questions:

What information will guide your practices?

What are common themes threaded throughout this presentation?

How can communication be strengthened for better understanding and outcomes?

6

Introduction of Presenters:

Lisa Baron, Ed.D. Program Director, Alliance for Inclusion and Prevention

Erika Tullberg, MPH, MPA is the principal Investigator at NYU Child Study Center’s  

Adam Brown, PsyD is Associate Director of the NYU Center on Coordinated Trauma Services in Child Welfare and Mental Health at the NYU Child Study Center. 

Trauma Systems Therapy

Clinical model for the efficient and effective treatment of traumatized children

AND

an organizational model for delivering services

TST is both a…

A traumatized child who

experiences survival-in-the-

moment states in specific definable

moments

A social environment

and/or system of care that is not able to help the child to regulate these survival-in-

the-moment states

The Trauma System

Social/environmental interventions

Emotion regulation interventions

Legal advocacy

The 4 Service Elements

Psychiatry/Psychopharmacology

Home and Community-Based Services

Psychotherapy

Legal Advocacy

TST is a team-based approachwho is on the team?

youthcaregiver

school teacher

cliniciancase worker

direct care staff

after school staff extended family

Determine where partnerships are needed

• Do all the people (the 4 service elements) work for my organization?

• If these people work for my organization; do they work in the part of the organization that will be doing TST?

• If they work for another part of my organization; how can I form a partnership with that area of my organization so that they will be ‘at the table’?

• If my organization does not have all 4 service elements, is there an organization that we work with who provides one or more of these elements?

• How can we form a partnership/collaboration with that organization to get those people ‘at the table’?

Success stands or falls on whether a strong working alliance can be formed.

The Working Alliance is defined as:

The agreement between the organizations to work on a specific

problems, in specific ways, towards a set of specific solutions.

Important Questions

1. How much do you know about how your partner organization defines its major sources of pain (their top priorities for their organization)? What is the language they use to describe these priorities?

2. How much does the TST program align with these priorities?

3. What is the plan for building the connection between #1 and #2 -- how do we make TST a win-win?

Presentation provided for your use by Glenn Saxe, MD, and B. Heidi Ellis, PhD, of the Center for Behavioral Science at Children’s Hospital Boston.

All rights remain with the authors.

TST creates strong collaborations through Organizational Engagement and Planning

Organizational Ready-Set-Go!In order to effectively engage a partner organization, we need to understand, from the perspective of its leaders, what is most important to its mission and what is its “major sources of pain”, what is getting in the way of it accomplishing its mission?

The we explore how TST can help to address those sources of pain.

Critical Collaborators

1) The Champion: The person who sees the possible value of TST for their organization and wants to bring it in;

2) The Gatekeeper: The person (usually a higher level administrator) who’s support of the program is absolutely necessary for this to work. What does she need to open that gate?

Presentation provided for your use by Glenn Saxe, MD, and B. Heidi Ellis, PhD, of the Center for Behavioral Science at Children’s Hospital Boston.

All rights remain with the authors.

Key Stakeholders Considerations

• Who in my organization needs to support the plan for this to work? How can I get their support?

• Who outside my organization needs to support the plan for this to work? How can I get their support?

• What does my staff need to get their support and investment?

Presentation provided for your use by Glenn Saxe, MD, and B. Heidi Ellis, PhD, of the Center for Behavioral Science at Children’s Hospital Boston.

All rights remain with the authors.

Considerations continued…

• How interested are my staff in doing TST?• Have they contributed to the organizational plan?• What might they be thinking when I say we are trying

to bring a new program here? • Have we ever tried to bring a new program here?

What happened? What was the experience of the staff?

• What is the plan to engage and train the staff?• What do my staff need to be supported to do this? • What is most important to my staff related to how TST

can fit for them?

Organizational Ready-Set-GoGoals

• Establishing an alliance with the key stakeholders• Educating and providing sufficient information to

key stakeholders about trauma, TST treatment and how TST will address the org’s highest priorities

• Troubleshooting practical barriers to the organization’s capacity to implement TST

Presentation provided for your use by Glenn Saxe, MD, and B. Heidi Ellis, PhD, of the Center for Behavioral Science at Children’s Hospital Boston.

All rights remain with the authors.

As in good clinical care the alliance must be checked and rechecked

over time

Presentation provided for your use by Glenn Saxe, MD, and B. Heidi Ellis, PhD, of the Center for Behavioral Science at Children’s Hospital Boston.

All rights remain with the authors.

What is the best way of making this work over time?

• Set up an evaluation system that allows you to track progress on participating organizations top priorities over time

• Make this evaluation system and its results a part of your regular discussion with stakeholders

• Adjust plan based on progress

Presentation provided for your use by Glenn Saxe, MD, and B. Heidi Ellis, PhD, of the Center for Behavioral Science at Children’s Hospital Boston.

All rights remain with the authors.

TST is currently being implemented in agencies in 14 U.S. States, and the country of Singapore, including programs that provide:

• Outpatient therapy• Residential treatment• Foster Care• Refugee services• Substance-abuse/MH services• Community based prevention• School-based mental health

TST Innovation Community

Example

Connecting With Care: A TST Innovation in the Boston Public Schools

Lisa Baron, Ed.D.Program Director Alliance for Inclusion and Prevention

IDEA Partnership WebinarTST: Collaborative Approaches, Techniques and PracticesMarch 6, 2015

Connecting With Care A School-Community Collaboration to Promote Children’s Mental Health

Connecting With Care (CWC) Program Overview:• Developed by AIP in collaboration with key community

stakeholders to address racial, ethnic disparities in children’s mental health access and treatment

• Expanded over 8 years to a total of 15 schools (K-8) in Boston neighborhoods with low SES, high immigrant populations, high violence/trauma

CURRENT AND FOUNDING PROGRAM PARTNERS, FUNDERS, AND SCHOOLSBrighton-Allston Mental Health AssociationFamily Service of Greater BostonHome for Little WanderersMSPCCNorth Suffolk Mental Health AssociationBoston Children’s HospitalNew York University Child Study CenterMassachusetts General HospitalRobert Wood Johnson FoundationAmelia Peabody FoundationBennett Family FoundationBlue Cross Blue Shield of MA FoundationBoston Foundation Hestia FundCabot Family Charitable Trust Cummings FoundationMA Attorney General’s Office

Adams ElementaryBTU Pilot K-8 Frederick Pilot MiddleGardner Pilot Academy Mather ElementaryMattahunt Elementary McKay K-8 Holland ElementaryHolmes Elementary Irving MiddleQuincy ElementaryTaylor ElementaryTimilty Middle Umana AcademyYoung Achievers Pilot

CWC is about Partnerships

CWC Goals

1) Better access to children’s mental health services2) Full-time mental health clinicians in schools3) Improve the quality of service delivery in schools

• Secure “buy-in:” Partnership brokering (schools and agencies)• Coordination (making the finances work for the agency)• Data collection (finance, utilization, TST, and clinical outcomes)• EBPs, including the first school-based adaptation of TST

Why is TST a good fit for schools?• Response to community request for specialization in treating children

exposed to high rates of violence and trauma in a school setting• Directly addresses teachers’ “source of pain:” Disruptions to teaching

and learning (disruptive behaviors and quiet dissociative types) • Daily contact with teachers and staff helps them understand the

behaviors they see and respond in more helpful ways• Demonstrated effectiveness in Boston (2005) with children and families• Integrates work within the service system of the Children’s Behavioral

Health Initiative in Massachusetts (CBHI)

Middle School Student, “Henry”

• Henry has experienced multiple moves and chronic homelessness living with his abusive, alcoholic father

• Henry and his family recently moved from New Mexico to Massachusetts where his mom lives, but he doesn’t see her often

• As a younger child, Henry was often awakened by his drunk father and beaten up “for no reason.”

• Now, Henry often has to retrieve his father, the primary caregiver, from the bars late at night

• Henry can “black out” and behave violently when he perceives he is being treated unfairly

• Henry is only 12

Working with Teachers

• Train teachers and staff in TST-informed interventions to provide an infrastructure of support for students

• Clinician observes Henry’s behavior (class, lunchroom, etc.) and gets the teacher’s perspective on what gets Henry upset, when, and where

• In consultation with Henry’s teachers, the clinician works through the TST analytical process:• Theme of environmental threat (perceived injustice)• Theme of Henry’s response (yelling, throwing things, leaving the

classroom)

Working with Teachers (continued)

• Help them understand that Henry is reacting to perceived injustices, based on his traumatic experiences

• Help them choose alternative responses to problem behaviors• Maintain clear and consistent expectations• Empathize with Henry’s experience of “injustice”• Establish “time out” space• Establish signal to allow Henry to go to an alternative space when

triggered• Lunch together one day/week to build trust and rapport

Working with the Family and Larger System

• Engage in-home therapy supports to address the family’s “sources of pain”• Find housing closer to Boston• Help dad find support for his alcohol addiction• Parenting skills to improve the parent/child relationship

• Maintain treatment alliance with providers• Regular communication• Ensure everyone is following TST treatment plan• Address any barriers to family’s treatment engagement• Attend TST team meetings whenever possible• Inform providers of important school meetings

Working with the Student

• Teach Henry how to understand and begin to regulate his emotions (build coping skills, access “safe space”)

• Gradually challenge Henry’s distorted thoughts that disrupt relationships with teachers and peers

• Work with teachers around finding opportunities for Henry to experience success and build his own “buy-in” to school

• Assisting teachers with tasks• After-school enrichment• Positive phone calls home

Challenges for TST Implementation in Schools

• Staff turnover:• School: principals and teachers

• Agencies: administration, supervisors

• Hiring of clinicians must follow school schedule

• Agency employers are reluctant to give up potentially “billable” time for TST team meetings

• Family engagement

School-Based Adaptations to Address Challenges

• CWC provides TST-informed training for teachers, staff, and agency providers so they can “Learn the Language” of TST trauma treatment

• Clinicians are hired during the summer for a September start date

• Afterschool training and weekly multi-agency, multi-school supervision to CWC clinicians

Special Challenge: Family Engagement

• Schools generally make the referrals, unlike clinic-based services

• Clinicians are coached in how to approach parents from the first phone call; principles of “Ready-Set-Go” implemented at start of all treatment

• In 2 years, CWC Clinicians’ family engagement increased by 80%:• 10% in 2009-10• 18% in 2011-12

TST OutcomesTrauma Systems Therapy (TST):CWC collects data on Fidelity and Outcomes on TST.** For the 43 children in the sample (2009-11):

*Statistically significant T-test results**Data reviewed and certified by Dr. Saxe and his research team

Decrease in Child’s Level of Emotional Dysregulation 33.73%*Decrease in Child’s Level of Dangerous Behaviors 30.43%*Decrease in Repeat Exposure to Trauma or “Triggers” 35.82%*Improvement in Caregiver Ability to “Help and Protect” Child 27.02%*Improved Service System Ability to “Help and Protect” Child 18.01%

Conclusions

• CWC is a school-based mental health model that deeply integrates school and mental health partnerships using TST practices and principles

• CWC data demonstrates that TST is an effective model for the treatment of trauma in schools

Resources

• http://www.rwjf.org/en/library/research/2012/11/connecting-with-care-in-low-income-boston-neighborhoods.html

• Kilkenny, R., Katz, N. and Baron, L. “Leveraging Mental

Health Dollars into Your District.” School Business Affairs,75(7): 11-15, 2009.

• www.aipinc.org

Presentation Title Goes Here 42

Addressing the needs of professionals impacted by

trauma

A traumatized child who

experiences survival-in-the-

moment states in specific definable

moments

A social environment

and/or system of care that is not able to help the child to regulate these survival-in-

the-moment states

The Trauma System

A traumatized child who

experiences survival-in-the-

moment states in specific definable

moments

A social environment

and/or system of care that is not able to help the child to regulate these survival-in-

the-moment states

The Trauma System

Secondary traumatic stress is the emotional duress that results when an individual hears about the first-hand

trauma experiences of another.

Baird & Kracen, 2006

What is Secondary Traumatic Stress?

Secondary Traumatic Stress

Re-experiencing

ArousalAvoidancenumbing,

detachment,withdrawal

nightmares, triggers

anger, hyper-vigilance, trouble concentrating

What does this look like at work?

• Reactivity

• Negative bias, pessimism – can’t see or recognize success• Can be exacerbated by accountability focus, public scrutiny

• All-or-nothing thinking – loss of perspective and critical thinking skills

• Decreased self-monitoring – reduced self-care

• Reduction in collaboration

• Withdrawal and loss of social support – both at work and at home

• Factionalism – breakdown of work units

• Threat focus – see clients, peers, supervisor as enemy

Layers of Traumatic Stress

External pressures and perceptions

Working with other stressed systems

Organizational stress

Relationships with colleagues,

supervisors

Interactions with

traumatized children and

families

Addressing the needs of staff directly impacted

by trauma

Addressing the impact that trauma has on your

organization’s culture and functioning

Aspects of Traumatic Stress

Strategies

How can you better support your teachers and other frontline staff?

How can an individual-based strategy be adapted to address the organizational

impact of traumatic stress?

How can these strategies apply to your cross-system work with other agencies?

How will you know it when you see it?

• Reactivity

• Negative bias, pessimism

• All-or-nothing thinking

• Decreased self-monitoring

• Reduction in collaboration

• Loss of social support

• Factionalism

• Threat focus

Which of these is most relevant to your setting?

How can you operationalize and track them?

From didactic training to skill building

© 2011 Resilience Alliance, ACS-NYU Children’s Trauma Institutehttp://www.nctsn.org/products/nctsn-affiliated-resources/resilience-alliance-promoting-resilience-and-reducing-secondary-trauma

Reframing “Self-Care”

What would it mean for a unit or department to have a self-care plan? For your school or agency?

How does the trauma experienced by your studentsplay out among staff?

Between your staff and other agencies you collaborate with?

How can we apply the strategies used with families to ourselves?

Parallel Process

Recognizing the Positive

How do you/your colleagues talk about children you’re struggling with?

How do you talk aboutthe other systems/agenciesyou collaborate with?

How do they/you balance what has gone well with what needs to improve?

Look at Language

Do people have permission to honestly acknowledge the challenges of the work?

Does this feel threatening to people? To whom?

Is this just venting, or can it be productive?

57

Resources

• National Child Traumatic Stress Network • http://

nctsn.org/resources/audiences/school-personnel

• http://www.nctsn.org/resources/topics/secondary-traumatic-stress

• Trauma-Aware Schools • https://

traumaawareschools.org/secondaryStress

• Compassionate Schools• http://

www.k12.wa.us/compassionateschools/pubdocs/theheartoflearningandteaching.pdf

Scott Bloom, LCSW-RSBLOOM5@SCHOOLS.NYC.GOV

Sandy Schefkind, MS, OTR/LSSCHEFKIND@AOTA.ORG

The Annual School Mental Health Conference will be held November 5-7, 2015 at the Sheraton New Orleans Hotel in New

Orleans, Louisiana. The theme of the conference is Getting Jazzed about School Mental Health - Celebrating 20 Years of

Advancing School Mental Health.