Division of Care and Treatment Services

TIC:

Trauma-Informed Care

Trauma-Informed ConnectionScott Webb, MSE

Trauma-Informed Care Coordinator

April 17, 2020

2

Learning Objectives

▪ Define and identify key terminology and concepts

related to trauma

▪ Understand the significance of the Adverse

Childhood Experiences (ACE) Study as it relates to

mental illness across the lifespan

▪ Articulate what trauma-informed care is, and be

able to identify the five pillars of trauma-informed

culture change for an organization

3

Recent Headlines

“Adult disease can

best be understood as the manifestations of distant childhood events.

Dr. Vincent FelittiACE Principle Co-Investigator

August 2010

5

Be Gentle on Yourself

BreatheSelf empathyPositive self-talkCount to tenUse fidgetsFeel feet on floorDoodleGet up and walk around

Trauma Defined

7

What is trauma?

▪ It is literally a wound. ♦ Greek derivation: (τραύμα)

▪ Disease of disconnection (Judith Herman, MD)

▪ Traumatic events are external, but they quickly become

incorporated into the mind. (Terr, 1990)

▪ It is extreme stress. (threat to life, bodily integrity, or

sanity)

▪ It is subjective.

▪ It lives in the body.

8

What is trauma?

▪ It often interferes with relationships.

▪ It affects the fundamental beliefs about oneself

and others.

▪ It causes one to question their place in the world.

▪ It’s a lot more common than you think.

9

Why are so many talking about

trauma?

▪ Disclosure

▪ Prevalence

▪ Science

▪ Services

▪ Hope

10

Photo: Homeboy Industries

Father Gregory Boyle

11

The Many Faces of Trauma

▪ Acute

▪ Complex

▪ Historical

▪ Sanctuary

▪ Vicarious

12

Sandy Hook Columbine Cooperative, 2017

Impact of Trauma

13

At least half of all adults in the U.S. have experienced one incident that was caused by a major

traumatizing event

(Briere and Scott, 2006)

14

Sixty eight percent of the healthcare workforce have experienced at least one episode of violence, abuse

or neglect

(Maundler, Peladeu, Savage, et al. 2010)

15

What Does the Prevalence Data Tell Us?

▪ Many with trauma histories have overlapping problems

with mental health, substance use disorders, physical

health and are victims or perpetrators of crime

▪ Those with traumatic lived experience are found across all

systems of care

S. Covington, Ph.D

Adverse Childhood

Experiences (ACEs)

17

ACE Study

It was designed to examine the health and social

effects of ACEs throughout the lifespan among

17,421 members of the Kaiser Health Plan in San

Diego County.

18

ACE Study

What do we mean by ACEs?

▪ Childhood abuse and neglect

▪ Growing up with domestic violence, substance use

disorder, mental illness, parental discord, and/or

crime in the home

(Anda, 2013)

19

▪ are common

▪ are intergenerationally passed

▪ have a cumulative effect—the higher the score, the higher the likelihood of health risk behaviors and poor health outcomes

▪ are NOT destiny!

Adverse Childhood Experiences:

20

Types of Stress Responses

21

of Wisconsin

residents have

at least 1 ACE

Findings from the 2015-2018 Behavioral Risk Factor Survey

22

ACEs and Mental Health

5%8%

14%

29%

5%8%

14%

28%

10%

16%

24%

43%

0%

10%

20%

30%

40%

50%

0 ACEs 1 ACE 2-3 ACEs 4+ ACEs

Current Anxiety Frequent Mental Distress

Lifetime Depression Diagnosis

Findings from the 2017-2018 Behavioral Risk Factor Survey

23

ACEs and Physical Health

7% 9% 10%15%

12% 14%17%

26%30% 32% 33%

40%

0%

10%

20%

30%

40%

50%

0 ACEs 1 ACE 2-3 ACEs 4+ ACEs

Asthma Fair/Poor General Health Obesity

Findings from the 2017-2018 Behavioral Risk Factor Survey

24

Household Dysfunction

7%

16%

16%

23%

26%

Incarceration

Mental illness

Violence between adults

Parent separate/divorce

Substance abuse

2011-2015 Behavioral Risk Factor Survey

25

28%

17%

10%

Emotional

Physical

Sexual

Abuse28% of Wisconsin residents grew up experiencing emotional abuse.

Findings from the 2011-2016 Behavioral Risk Factor Survey

26

ACEs Impact Over Lifespan

26

▪ Neurological

▪ Biological

▪ Psychological

▪ Social

▪ Mortality

27

28

Trauma disrupts neurodevelopment

Person experiences trauma

Brain and body become overwhelmed; nervous system is unable to return to

equilibrium

Trauma goes untreated; person stays in “stress response” mode

Cues continue to trigger trauma (e.g. loud noises, smells, textures)

Person reacts to trauma cues from a state of fear

“The peace of mind

you deserve in the present is held hostage by the terror of your past

-Lily Burana

Illustration: The Triune Brain, By Lchunhori at English Wikipedia

31

Healthy Brain and Abused Brain

CDC

32

Reminders or “Triggers”

A trigger can be a person (or approach), place,

thing, time, event, date, smell, or texture.

33

Reminders or “Triggers”

▪ Lack of control

▪ Threats or feeling threatened

▪ Isolation

▪ Authority figures

▪ Being told what to do

▪ Lack of privacy

▪ Separation or loss

▪ Transitions or disruptions in

routine

▪ Being touched or

watched

▪ Loud noises

▪ Intrusiveness

▪ Being locked in a room

▪ Being ignored

▪ Condescending looks

34

Elder-Specific Traumatic Experiences

▪ Loss of spouse and peers

▪ Chronic and life-threatening diagnosis

▪ Physiological changes, limitations and disability

▪ Cognitive and memory loss

▪ Loss of roles and resources

▪ Increased dependence on caregivers

▪ Unavailability of caregivers (COVID-19)

Question: How does having a trauma history compound these later-in-life traumas?

Gabriela Grant, 2019

35

Trauma and the Elderly

One thing to keep in mind when considering how

often older adults face new traumas or stressors…

Any change involves loss.

Loss needs to be grieved.

36

Trauma and the Elderly

Many factors make it more or less difficult for elders

before, during, and after traumatic events

♦ Impaired cognition, mobility, or senses

♦ Decreased or unavailable social network (COVID-19)

♦ Mental or medical problems

♦ History of exposure to extreme traumatic stressor

♦ Substance use disorder

♦ Language or cultural barriers

37

Trauma Can Complicate Aging

▪ Trauma poses a threat to the successful aging process by interfering with interpersonal relations and productive activity (Cisler et al., 2010; Rowe and Kahn, 1997)

▪ Contrary to previous assertions of resiliency in older adult populations, there is reason to suspect greater vulnerability to emotional difficulties following exposure to traumatic stressors in this population (Grey and Acierno, 2002)

38

Post-Traumatic Stress Disorder

Assessment for Elders▪ Post Traumatic Disorder Checklist

♦ Validated for older adults (Hudson, et al., 2008)

▪ Trauma Symptom Checklist – 40 (Briere)

♦ General for adults (age specific for children)

▪ Stressful life experiences checklist

▪ ACE Questionnaire

39

Brief Trauma Screen

▪ Do you feel safe speaking to me today?

♦ If not, what would help you feel safer?

▪ Do you feel safe at home today?

♦ If not, how can we help you feel safer?

▪ Did you feel safe at home as a child?

♦ If not, how does that affect you today?

Developed by Gabriela Grant

40

The Trauma World View

• No place is safe• My own actions, thoughts,

and feelings are unsafe• Other people are unsafe and

can’t be trusted• I expect crisis, danger and

loss• I have no worth and no

abilities

41

Outward Expressions Inward Expressions

Explaining, not Excusing Behaviors

▪ Anger or defiance

▪ Violence towards others

▪ Truancy

▪ Criminal acts

▪ Perfectionism

▪ Withdrawal

▪ Substance use disorder

▪ Violence towards self

▪ Spacing out

▪ Perfectionistic

42

A Trauma World View Requires a Shift

43

Do No Harm

“We need to presume the clients we serve have a

history of traumatic stress and exercise universal

precautions by creating systems of care that are

trauma-informed.”

(Hodas, 2005)

44

Over-Arching Concept

Trauma must be seen as the expectation, not the

exception, in behavioral health treatment systems

(Rosenberg, 2011)

45

Being Trauma-Informed

46

What is Trauma-Informed Care?

▪ Principle-Based culture change process

▪ Acknowledges the pervasiveness of trauma

▪ Focused on how trauma may effect an

individual’s life and their response to support

services

▪ Safety for all

▪ Atmosphere of trust

▪ Compassionate collaboration

▪ Strengths-based

47

What is Trauma-Informed Care?

▪ Aims to avoid re-traumatization

▪ Appreciates many problematic

behaviors began as

understandable attempts to cope

▪ Strives to maximize choices for

the survivor and control over the

healing process

▪ Seeks to be culturally competent

▪ Understands each survivor in the

context of life experiences and

cultural background

(Alvarez and Sloan, 2010)

48

Trauma-Informed Care

▪ Is not an intervention to address posttraumatic

stress disorder

▪ Is not a “flavor of the day” approach

▪ Is not age limited

49

Wisconsin’s TIC guiding principles

“The oldest medicine

in the world is love and

compassion”

VADM Vivek Murthy, M.D.

Former United States

Surgeon General

50

Working with People with Traumatic

Experiences ▪ They are not victims.

▪ The labels we use to describe these people keep them

trapped in their story.

▪ When we label, we judge.

▪ When we judge, we lose the ability to connect

meaningfully with these people.

▪ They are people who have had a unique opportunity to

develop a set of strengths and resiliency factors we need to

understand – they need to feel safe enough to share with

us

51

Working with People with Traumatic

Experiences ▪ This process starts before they walk in the door: What

is your organization’s reputation in the consumer

community? (Do you know?)

▪ Requires us to become aware of their awareness.

♦ Is the waiting room calm and welcoming?

♦ Are the support staff friendly and helpful?

♦ What are some perceptual barriers we may not have

thought about?(Michael G. Bricker, MS, CADC-II, LPC, 2018)

Five Primary Trauma-Informed Care Values

• Safety• Trustworthiness• Choice• Collaboration• Empowerment

Fallot and Harris, 2006

53

Value-Based Practice: Safety

▪ Create a welcoming, calming environment

▪ Maintain respectful physical and emotional

boundaries

▪ Provide a safe place to talk

▪ Be open to outside parties, advocacy, and clinical

consultants

▪ Ask about current abuse and address current risks

to safety (Fallot and Harris, 2002)

54

Comparison

TraditionalKey Question: “What’s

wrong with you?”

▪ Elder isn’t fitting well

here, has limited social

skills, not making

friends, isolating

▪ Not remembering

anything

Trauma-InformedKey Question: “What happened to you?”

▪ Experienced a significant loss or transition recently?

▪ Is there a medical condition? Medication interaction? Trauma history?

55

Re-traumatization

▪ A situation, attitude, interaction, or environment

the replicates the events or dynamics of the

original trauma (a trigger)

▪ Can be obvious, or not

▪ Usually unintentional

▪ Always hurtful

56

Responding to People in Need

Listen (Active listening)ValidateNormalizeAssistAvoid re-traumatization

57

More on Validation

▪ “What happened was not your fault”

▪ “You are not to blame for what happened to you”

▪ “Thank you for trusting me with such a personal

and private experience”

▪ “You deserve help in dealing with something so

difficult. Would you like me to connect you with

someone you could talk to about this?”

(Aurora Health Care, 2016)

58

What Does TIC Look Like?

▪ Avoid forcing eye contact

▪ Be aware of your proximity

▪ Avoid asking too many questions

▪ Pace client meetings by offering breaks

(water, stretch, etc.)

▪ Draw upon past success

▪ Ask before touching or hugging

▪ Provide choice when possible

▪ Ask about the client’s goals and priorities

59

What Does TIC Look Like?

▪ During emotional times ask “How can I support you right

now?”

▪ When the trauma story overwhelms or leaves you

speechless, be willing to sit in supportive silence

▪ Provide clear information about when, where, and by

whom services will be provided

▪ Be prepared to repeat information many times; repetition

is commonly needed when patients are working with an

overwhelmed nervous system

60

Value-Based Practice:

Compassionate Communication▪ Use person-first language (not diagnosis-first

language)

▪ Empathy before education

61

Value-Based Practice:

Compassionate CommunicationAvoid using de-humanizing language:

▪ Manipulative

▪ Non-compliant

▪ Attention-seeking

(Aurora Health Care, 2016)

62

Important to Broaden Our View of TIC62

▪ For years we have thought about TIC in age

groups: kids, adults, and older adults

▪ We need to begin to think about TIC in ages

across the lifespan!

Gloria Dixon, DNP, PMHN-BC, 2018

63

Important to Broaden Our View of TIC63

The following concepts apply to all ages:▪ Person-centered planning▪ Compassionate communication▪ Confidentiality▪ Comfort▪ Trust and respect▪ Recovery concepts▪ Collaboration▪ Education for all staff

Gloria Dixon, DNP, PMHN-BC, 2018

64

Adult Protective Service and Aging

Staff Interventions64

• Psychological First Aid for Seniors (Crisis Intervention)http://amhd.cbcs.usf.edu/docs/pfanh2ed.pdf

• Seeking Safety (PTSD and Substance Use Disorder)www.seekingsafety.org

• Cognitive Behavioral Therapy for Late-Life Depressionhttp://oafc.stanford.edu/projects/cbt.html

• IMPACT (Depression)http://impact-uw.org

65

Adult Protective Service and Aging

Staff Interventions65

• Responding to Violent Crimes Against Persons with

Disabilitieshttp://www.safeplace.org/page.aspx?pid=358

• Preventing Suicide and Promoting Well-Beinghttp://store.samhsa.gov/product/SMA10-4515

66

Be Attentive

Language Matters

Your Words Have Power

Use Speech Free From Labels,

Jargon, and Judgments

67

Thank You!

Scott A. Webb, MSE

608-266-3610

scott.webb@dhs.wisconsin.gov

Join the TIC Email ListVisit dhs.wisconsin.gov/tic to sign up to receive email notices for

trauma-related research, resources, training opportunities, etc.