Trauma Informed Care

1. Trauma Informed Care

2. Matt Tice Oksana Kaczmarczyk MSW, LCSW University of Buffalo Matt Tice has worked his way through the ranks of Pathways to Housing PA, first as an Assistant Team Leader in 2012, then as a Team Leader, and then as Clinical Director in 2014. MSW, LCSW, Rutgers University Over 9 years of clinical experience working with adults diagnosed with severe mental illness (SMI) and/or substance use D/O. Completed a training course in Cognitive Behavioral Therapy (CBT) through the Beck Institute and use CBT as the main treatment modality.

3. Disclaimer on Trauma-Informed Care • One 2 Hour Training Does not make you or your organization Trauma Informed • Trauma-Informed Care is an over-arching philosophy and approach, NOT a program

4. Why do we need to this? • People can overcome traumatic experiences with appropriate supports • Most go without the supports Significant incidence with those we serve Unaddressed trauma increases the risk of: • Mental illness • Substance use disorders • Chronic physical diseases

5. What is Trauma Informed Care (TIC)? • “A program…that is trauma informed: • realizes the widespread impact of trauma and understands potential paths for recovery; • recognizes the signs and symptoms of trauma in clients, families, staff, and others involved In the system; • responds by fully integrating knowledge about trauma into policies, procedures, and practices, and seeks to actively resist re-traumatization” • (Oral et.al, 2016)

6. The four Rs • Realization- All people at All levels of the organization or system understand how trauma can affect individuals, families, communities • Recognition- screening and assessment; trainings and supervision

7. The four Rs • Respond- the organization is committed to providing a physically and psychologically safe environment • Resist re-traumatization- the organization recognizes that some practices may trigger traumatic emotions and teach the staff to recognize these (For ex. Involuntary commitment to treatment (302)) • (SAMHSA, 2014)

8. Key components of TIC (SELF) • SAFETY • Help: • recognize how the participants view safety • create a safety plan to reduce threats • think through how they can become safer (physically, psychologically) (http://nnhvip.org/trauma-informed-care)

9. Key Components of TIC • EMOTIONAL MANAGEMENT • Help: • become less reactive • develop trust • think more clearly • develop adaptive coping strategies (http://nnhvip.org/trauma-informed-care)

10. Key Components of TIC • RECOGNIZE THE LOSSES • LOOK TO THE FUTURE • Help envision what they want in their future • Support as participants name, define, and move forward toward achieving their goals • (http://nnhvip.org/trauma-informed-care)

11. Key components Collaboration and Mutuality • Leveling of power differences between staff and clients and among organizational staff • Everyone has a role to play in trauma informed approach • One doesn’t have to be a therapist to be therapeutic

12. Empowerment, voice, and choice Organizational level • The experience of trauma is a unifying aspect in lives of those who run the organization, provide direct services and those who come to the organization for services • Operations foster empowerment of staff and clients Individual level • Support clients’ self-advocacy skills • Be the facilitator of recovery rather than the controller of recovery • Empower client’s decision making and goal attainment

13. Cultural, Historical and Gender issues Organizational level • Actively moves past stereotypes and biases • Recognizes and addressed historic trauma Individual level • Recognizes own biases and processes them in supervision • Develops culturally sensitive practices

14. “There are some people who are so traumatized they might never recover, but I need to consider how I can give them a better quality of life here and now”. • Be mindful of “vicarious trauma”. • Supervision is important and needed! • Adjust supervision time and frequency to the individual’s needs (Prestidge, 2014)

15. What is Trauma? • What comes to you when you hear the word “Trauma”? • What types of events do you consider “traumatic”?

16. Trauma as defined by Webster • a very difficult or unpleasant experience that causes someone to have mental or emotional problems usually for a long time • medical : a serious injury to a person's body • a disordered psychic or behavioral state resulting from severe mental or emotional stress or physical injury

17. More on Trauma • An event in which one feels terrified (a loss of safety) and helpless (a loss of control) may be the trigger of the experience of trauma

18. “Individual trauma results from an event, a series of events, or set of circumstances that is experienced by the individual as physically or emotionally harmful and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well –being” • (SAMHSA, 2014)

19. Precipitating Factors Physical • Medical • Drives • Fatigue Psychological • Development • Needs to Belong • Displaced Anger • Loss of Control • Frustration Environmental • Too Hot/Cold • Too Close/Crowded • Loneliness • Staff

20. PTSD Defined • Exposure to actual or threatened death, serious injury, sexual violence in one of the following ways: • Direct experience of the event • Witnessing • Learning that traumatic event occurred to close family or friends • Repeated exposure to aversive details of the traumatic event (e.g., first respondents collecting human remains) • Note: this excludes exposure to details through media • (DSM-5)

21. PTSD Defined • The person exhibits at least one of the following: • Recurrent, involuntary memories of the traumatic events • Recurrent distressing dreams with content related to traumatic events • Flashbacks • Intense psychological distress at exposure to internal/external cues that resemble traumatic events • Marked physiological distress • (DSM-5)

22. PTSD Defined • Persistent avoidance of stimuli associated with the traumatic event as evidenced by: • Efforts to avoid distressing memories • Efforts to avoid external reminders (e.g., places, conversations, activities) • Any examples of participants you can think of?

23. PTSD Defined • Negative alterations in conditions and mood associated with the traumatic event as evidenced by at least one of: • Inability to remember an important aspect of the event • Persistent negative beliefs about oneself, others, and the world • (DSM-5)

24. PTSD Defined • Persistent, distorted cognitions about the cause or consequences of the TE that lead to self blame • Persistent negative emotional state • Markedly diminished interest in activities • Feelings of detachment from others • Persistent inability to experience positive emotions • (DSM-5)

25. PTSD Defined • Individuals with PTSD may experience any one ore more of the following: • Irritable behavior and angry outbursts • Reckless behavior • Hypervigilance • Exaggerated startle response • Problems with concentration • Sleep disturbance • (DSM-5)

26. Not all trauma is the same • Sexual abuse/assault • Physical abuse/assault • Emotional Abuse • Neglect • Serious accident/ illness • Medical procedure • Witness to domestic violence School violence • Natural or Man made disaster • War/terrorism/political violence • Victim/witness to extreme personal/interpersonal violence • Traumatic grief / separation • Victim/witness to community violence

27. Complex Trauma • Interpersonal • Premeditated • Caused by other humans (mostly caregivers) • Causes more severe reaction/psychological harm • Repetitive • Prolonged • Early onset “Simple” Trauma • A single event • Impersonal events (house fire; floods; car accidents) • Generally people respond in a supportive way

28. Childhood Adulthood • Severe and repeated abuse leads to inability to self-soothe, trust and view the world as a safe place • Poor judgement, varying degrees of paranoia, self-sabotage and impaired problem-solving skills

31. Adverse Childhood Experiences

32. TIC when working with people experiencing homelessness The potential causes of trauma: • Losing home • Life in “shelters” • Life on the streets • Abuse before homelessness • “Abuse” during homelessness

33. Key Strategies Trauma Awareness • Educate both: trauma survivors and the staff working with them • Understand the physical and cognitive impact of trauma • Understand how individuals relate to the external world. • Help establish an internal sense of safety • Why is it important for staff to be aware of the impact of trauma? • (Prestidge, 2014)

34. Key Strategies • TRAUMA AWARENESS • Helps not take things personally • Helps not see things in black and white only • Eliminates the feeling “I can’t win with this one” • Understand that they can’t “fix” the person but be a consistent support for him/her • (Prestidge, 2014)

35. Key Strategies • Emphasis on safety and opportunities to rebuild control • Services are to be transparent with no “surprises” • Develop safety plans in advance • Mental illness, substance misuse are not shameful phenomenon • Learn about your client in advance (if possible) to learn their triggers

36. Key Strategies • Strengths-based approach • Treat with unconditional positive regard (acceptance and support regardless of what the person says; for the exception of safety issues) • Build upon individual’s positive behaviors rather than trying to change the negative ones

37. Key Strategies • Strengths –based approach • Encourage participants to have hopes and dreams AGAIN • “…when people have been hurt so much, they don’t even know what is possible for them…” • Recognize and acknowledge the small steps forward

38. From a TIC, diagnosis is less relevant • Symptoms are viewed as “normal responses” to trauma • Focus on helping them cope with their symptoms • Recognizes that clients use substances for adaptive reasons though there may be risky consequences (Harm Reduction)

39. If you are using some of the following words to describe your clients, you are most likely not practicing TIC: • “ unmanageable” • “unreachable” • “resistant” • “non-compliant” • “difficult” • “manipulative”

40. “…TIC…a powerful framework that provides Hope that there is a better way to handle some of our most pressing social problems…” (Prestidge, 2014)

41. Reminders • Remember: its not only the participants who experience traumatic events, staff may have had also. • Be mindful of the trauma your colleagues may have been exposed to. • Trauma has many ways of showing or hiding itself so you won’t always know who experienced trauma.

42. Trauma Informed Techniques Grounding Breath • Ask the client to inhale through the nose. Take twice as long as your inhale and slowly exhale through the mouth. • Have the client place his or her hands on his or her abdomen and then watch the hands go up and down while the belly expands and contracts. The Trauma Informed Check In • How are you doing? • What are your goals for the meeting/session/day? • Who are you going to ask for help to accomplish that goal?

43. Trauma Informed Techniques Centering • 5 Things you see • 4 Things you hear • 3 Things you feel Bonus • 2 Things you smell • 1 Thing you taste

45. Primary Care PTSD Screen

46.  • John was one of the newest referrals to your outreach department. John was described as “grumpy” and “difficult to engage”. After your first interaction with him, you thought to yourself “now I know why they said he was difficult. It is because he is. He is also rude and likes to challenge everything I say. He is gonna make my work harder than needs to be, but I am gonna show him who is in charge. He’s gotta do what I tell him to do if he wants to get housed”.

47.  • John was one of the newest referrals to your outreach department. He was described as “grumpy and difficult to engage”. After your first interaction with him, you tell yourself “ this man has been through a lot. He is a true survivor. I really understand now why he appears to be “difficult”. He just doesn’t trust people any more. I wouldn’t either if I experience all the terrible things he did. I know I will need to work on gaining his trust. I am going to show him that I really want to help him get into an apartment if this is something he really wants to do”.

48.  You meet Jackie (legal name Jackson) for the third time this week. She comes in to the office and complains about people trying to harm her. She talks about her neighbor who she claims calls her names and makes fun of her. She also tells you about this guy she sees often in the community, who threatened to beat the hell out of her. She also tells you that she smokes crack to deal with all this stress. You- “Jackie, how many times are we going to go over this? You are too sensitive to things. I am sure your neighbor doesn’t really mean to harm you. That guy that you keep talking about apparently threatened you many times, but hasn’t hurt you yet. I wouldn’t worry about it. I am wondering that the crack is making you paranoid”.

49.  You meet Jackie (legal name Jackson) for the third time this week. She is a trans woman. She comes in to the office and complains about people trying to harm her. She talks about her neighbor who she claims calls her names and makes fun of her. She also tells you about this guy she sees often in the community, who threatened to beat the hell out of her. She also tells you that she smokes crack to deal with all this stress. • You- “It must be very difficult for you to have to encounter hostility in the community. I know that going through a transition from one gender to another is full of challenges. We both know that there are higher rates of violence perpetuated against people in the transgender community. How are you coping with all of this? Let’s try to come up with a safety plan that will help you cope with some of the stress related to this. What do you think? Is this something you would like to work on?

50. American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th ed. • Bloom S.L. and Sreedhar S.. Y (2008) “The sanctuary model of trauma-informed organizational change”. Reclaiming Children and Youth, 17 (3) 49-53) • Oral R. et al (2016) Adverse Childhood Experiences and Trauma Informed Care: the Future of Health Care. Pediatric Research 79 (1)227-233 • Presidge, J. (2014) “Using Trauma -Informed Care to provide therapeutic support to homeless people with complex needs: a transatlantic search for an approach to engage the “non-engaging” . Housing, Care, and Support, 17 (4) 208-214