M E R C Y L I F E P A C EW E S T S P R I N G F I E L D , M A

An Introduction to Trauma Informed Care in IDT

K A T A R I N A H A L L O N B L A D , M S , O T R / LC A R M A R T H E N S W I F T , M S W , L I C S W

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 non-family 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

(Perry, 2010)

Normal Extreme neglect

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)

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.

Behavior as Means of Getting Needs Met

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

Parental employment

Adequate housing

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

(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/wp-

content/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/what-is-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