Trauma Informed Care Mandy A. Davis, LCSW madavis@pdx 503-725-9636

1. Trauma Informed Care Mandy A. Davis, LCSWmadavis@pdx.edu503-725-9636

2. Trauma Informed Care “Trauma-informed organizations, programs, and services are based on an understanding of the vulnerabilities or triggers of trauma survivors that traditional service delivery approaches may exacerbate, so that these services and programs can be more supportive and avoid re-traumatization.” (SAMHSA) Vs. Trauma Specific Services – intended to reduce trauma symptoms experienced by survivors. (EMDR, TFCBT, Seeking Safety, TREM, ATRIUM)

3. "With abuse, you suffer loss of soul, loss of self and loss of meaning""In the system, you must fight every day, every minute, to keep from feeling worthless - to keep your spirit alive" K.W. (Survivor) • Calling a client "noncompliant", "treatment-resistant" etc. rather than taking responsibility for failing to better help him or her, or for not knowing what to do or how to understand. • Accusing clients of "splitting" staff rather than staff taking responsibility for splitting themselves. Most of what passes for "splitting" is simply the person asking different people for what she/he wants, hoping for an alternative answer or an ally. • "Your history follows you no matter what you do in the present. I only got assaultive one time and that was when they tore the head off my stuffed doll that I had had for a lifetime. Now providers tell me I'm dangerous and I terrify people. My history follows me“ • I got traumatized because of trusting people, so asking me to make a contract with you demands I trust you - which I can't. • We know what works for us and what we need, but no one will listen or take us seriously. From “In Their Own Words: Trauma survivors and professionals they trust tell what hurts, what helps, and what is needed for trauma services” (1997) Jennings, A. and Ralph, R.

4. Trauma overwhelms • Can be single event. • More often multiple events, over time (complex, prolonged trauma). • Interpersonal violence or violation, especially at the hands of authority/trust figure, is especially damaging.

5. Prevalence of TraumaHigh in Community Samples • NVAW Survey (NIJ, 1995-96) • 52% of women report lifetime history of physical assault; 66% of men. • 18% of women reported rape or attempted rape at some time, many before age 18. • 22% of women reported domestic violence; 7% of men. • Adverse Childhood Experiences study (CDC, 1995) • 17,337 Kaiser enrolled adults • ACE score cumulative based on 10 experiences in childhood. • Includes but not limited to violent trauma.

6. ACE score includes: • Lack of nurturance and support (emotional neglect). • Hunger, physical neglect, lack of protection (homelessness). • Divorce in the home. • Alcoholism or drug use in home. • Mental illness or attempted suicide among household members. • Incarceration of household member. Two-thirds of sample had a score of 1 or more. More than 10% had score of 4 or more.

7. The Cumulative Impact • ACE study (scores 0-10) • Score of 4 or more: • Twice as likely to smoke • 12 times as likely to have attempted suicide. • Twice as likely to be alcoholic. • 10 times as likely to have injected street drugs. • Score highly correlated with: • Prostitution, mental health disorders, substance abuse, early criminal behavior. • Physical health problems, early death.

8. Adverse Childhood Experiences(www.ACEstudy.org)

9. When Trauma Happens…. • Fight, Flight, Freeze • Tend & Befriend (Taylor, et al) • Chronic Trauma, Complex trauma overtime

10. Impact of Trauma Fight, Flight……….& Freeze Tend and Befriend (Taylor, et al) • Emotional Reactions • Feelings – emotions, Regulation • Alteration in consciousness • Hypervigilence • Psychological and Cognitive Reactions • Concentration, slowed thinking, difficulty with decisions, blame • Behavioral or physical • Pain, sleep, illness, substance abuse, • Beliefs • Changes your sense of self, others, world • Relational disturbance **pay attention to how this intersects with getting basic needs met

11. Without helpful affect regulation skills people who are traumatized may have to rely on tension reduction behaviors -external ways to reduce triggered distress (Briere, 2004) • Address TRB and/or reduce distress • Has to match… • Chronic trauma interferes with neurobiological development and the capacity to integrate sensory, emotional and cognitive information into a cohesive whole. Developmental trauma sets the stage for unfocused responses to subsequent stress. • (Van der Kolk, http://www.traumacenter.org/products/pdf_files/Preprint_Dev_Trauma_Disorder.pdf )

12. Sue successfully completed her AOD treatment. Part of the safety plan for her to have her 4 y/o is no contact with her abuser. While out one day she runs into her ex-partner who was abusive. Her DHS worker finds out, confronts her about it and she doesn’t tell the truth saying “it never happened”. • Pat agrees to MH counseling in a team mtg but “no shows” for the intake. During follow-up she states she is very interested but “no shows” again. • Jack calls all of his providers, multiples times. The calls are often about the same thing. He is often asking for tangible goods & can be verbally aggressive. For example last week he called requesting bus tickets. One of his providers said “I think I can get you some” but he kept calling the other providers.

13. You are meeting with Sophie to complete paperwork to get services for her children as she requested. She keeps rustling through her bag while your talking, looking outside your office, and checking her phone. She can’t seem to settle down and focus. • You are meeting with Yumi after an altercation with another resident in your program. She quickly says it is not her fault, that the program is targeting her and the system is unfair. • Tim is completing an intake for your services. Your program has several rules and protocols that need to be followed to successfully complete. Tim’s referral states that he has difficulty with authority and following rules and doesn’t accept help from others.

14. A Trauma Lens • What might the NON-Trauma Informed system say about this person? • What we know about trauma is because/to 1. 2. 3. What we know about trauma is that trauma survivors often started using substances to either prevent feeling greater pain, to feel something, or because it was forced onto them.

15. Trauma Informed Services • Takes the trauma into account. • Avoid triggering trauma reactions and/or traumatizing the individual. • Adjust the behavior of counselors, other staff and the organization to support the individual individual’s coping capacity. • Allow survivors to manage their trauma symptoms successfully so that they are able to access, retain and benefit from the services. Harris, M., & Fallot, R. (2001). Trauma awareness Emphasis on safety Opportunities to rebuild control Strengths-based approach Hopper et al, 2010

16. The Foundation • Trauma Awareness • Trauma education and training for all staff; • Hiring, management, and supervision practices; • Policies and procedures for referral, intake, termination; • Recognition of vicarious trauma and the appropriate care of staff; • Universal precaution and/or universal screening; • Knowledge of effective trauma recovery services; • Advocacy within the agency and with partner agencies/systems. • Understanding of the impact of historical trauma and all forms of oppression • Ongoing training for all staff • Ongoing inclusion of consumer voice • Procedures and practices that promote and sustain accountability

17. Principles of Practice With a foundation of awareness and understanding, organizations can strive to reflect three central principles of TIC, by creating policies, procedures, and practices that: • create safe context, • restore power, and • value the individual.

18. Create Safe Context • Physical Safety • What does it look like? • Where and when are services? • Who is there/allowed to come? • Attend to unease. • Signage about what to expect, where to go… • Home visiting plans. • End with “whats next” - predict • Vicarious trauma prevention plans Is there anything I can do to help you feel more safe?

19. Create Safe Context cont… • Emotional Safety • Clear & consistent boundaries • Be able to state and model • Allowed to speak up re: vicarious trauma • Transparency • Explain the “why” • Eligibility written out and explained • Predictability • What next • Choice • True choice

20. Restoring Power • Empowerment • Advocate, model • May need to do for first • Choice • As much as possible • 3 options • Strengths Perspective (trauma) • Focus on the future • Skill building • Every encounter

21. Value the Individual • Respect • Life experienced valued • Collaboration • Referrals, teams, meetings • Compassion • Not an excuse but an explanation • Self Care • Relationship • Modeling, boundaries, learning, partnering • Supervision

22. What I say… • I wonder if….. • I notice…. • In times of stress it is difficult for our brains to retain information so to make sure we are on the same page can you repeat back …. • Accessing services can sometimes feel traumatizing • I am getting ready to ….. • Is there a way to make this more comfortable, safe, successful • Is that your understanding….

23. Be mindful of your words…. • Deny • Prioritize • Accountability • “Your kid is doing great” • “Well there is always a chance….” • “Do you want her to be worse off” • “It was your choice to…”

24. We want to provide the lens… • Asking: • Is trauma at play here? • Re-frame to a trauma explanation when appropriate. • Trauma education statements • Trauma translators

25. I think applying TIC principles in practice will: • Improve our desired outcomes (dependent on system) • decrease vicarious trauma or compassion fatigue • And support trauma recovery by • Reducing re-traumatization • Providing “corrective emotional experience” • Educating others

26. So – Now What? • Identify policies, practices, and/or experiences in your work that have potential to re-traumatize those accessing your services. • What is at least one thing you can do differently to be more trauma informed? Awareness, Understanding, Create safety, restore power, value the individual

27. http://www.familyhomelessness.org/media/90.pdf http://www.odvn.org/images/stories/FinalTICManual.pdf http://www.annafoundation.org/CCTICSELFASSPP.pdf http://www.socialwork.buffalo.edu/students/self-care/ • Prescott, L., Soares, P., Konnath, K., and Bassuk, E. (2008). A Long Journey Home: A Guide for Creating Trauma-Informed Services for Mothers and Children Experiencing Homelessness. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration; and the Daniels Fund; National Child Traumatic Stress Network; and the W.K. Kellogg Foundation. Available at www.homeless.samhsa.gov