Trauma Informed Care: A shift in thinking for service Providers in DE

1. Trauma Informed Care:A shift in thinkingfor service Providers in DE The Importance of Trauma Informed Care Kevin Ann Huckshorn RN, MSN, CADC DSAMH State Division Director Substance Abuse and Mental Health January, 2012 1

2. Outline What is trauma? What is Trauma Informed care (TIC)? How does TIC relate to people who are homeless and the settings that serve them? What are the differences between a Trauma Informed and uninformed service system? Steps in becoming Trauma Informed 2

3. What makes an event traumatic? Traumatic Events are: Sudden, unexpected, and extreme Usually involve physical harm or perceived life threat (research has shown that the perception of “life threats” are powerful predictors of the impact of trauma) People experience these events as out of their control Certain stages of life make people more vulnerable to the effects of trauma including childhood, teens and early twenties. All pre-suppose a greater impact on life in adulthood (Tedeschi, 2011) 3

4. Traumatic Life Events that can result in Mental Health Problems Are interpersonal in nature: intentional, prolonged, repeated Includes sexual abuse, physical abuse, severe neglect, emotional abuse Includes witnessing violence, repeated abandonment, sudden and traumatic loss Can occur in childhood, adolescence or at any time in an adult’s lifetime depending on extent (Terr, 1991; Giller, 1999, Felitti, 1998) The process of “becoming homeless” is widely believed to have exposed all involved to trauma; homelessness itself is traumatic (Hopper, Bassuk, & Olivet, 2010) 4

5. The Definition of TraumaInformed Care “Trauma Informed Care is a strengths-based framework that is grounded in an understanding of and responsiveness to the impact of trauma… that emphasizes physical, psychological, and emotional safety for both providers and survivors and…and, that creates opportunities for survivors to rebuild a sense of control and empowerment.” (Hopper, Bassuk, & Olivet, 2010, pg. 82) 5 Care that is stabilizing and addresses physiologic dysregulationCare that is stabilizing and addresses physiologic dysregulation

6. How is Trauma Defined? NASMHPD (2004): The experience of violence and victimization including sexual abuse, physical abuse, severe neglect, loss, domestic violence and/or the witnessing of violence, terrorism or disasters DSM IV-TR (APA, 2000): Direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to ones physical integrity; Or witnessing an event that involves death, injury, or a threat to the physical integrity of another; Or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or close other (Tedeschi, 2011) 6

7. Remember: Trauma is not just Sexual or Physical Abuse 7

8. So, what is “Trauma Informed Care?” Care that recognizes and respects that: Experiencing trauma represents a profound loss of control Trauma is not just a memory. It may have happened in the past, but it impacts the present and effects consumer’s: health & development, the ability to learn & function Ability to have healthy relationships and trust others Care must be collaborative, supportive, skill-based and focused on helping people reclaim control (Fitzpatrick et al., 1999; Jennings, 2004) 8 Care that is stabilizing and addresses physiologic dysregulationCare that is stabilizing and addresses physiologic dysregulation

9. How many people have experienced trauma? What about the people we serve? What about people in other care settings? 9 What is some of the research regarding the prevalence of trauma?What is some of the research regarding the prevalence of trauma?

10. Prevalence of TraumaMental Health Population – Adults 97% of homeless women with SMI: experienced severe physical & sexual abuse 87% experience abuse both in childhood and adulthood (Goodman et al, 1997) 90% of public mental health clients have: been exposed to trauma multiple experiences of trauma (Mueser et al, in press; Mueser et al, 1998) 81% of adults diagnosed BPD or DID (90%) were sexually or physically abused as children (Herman et al, 1989; Ross et al, 1990) 29-43% of people with SMI have PTSD (CMHS/HRANE, 1995; Jennings & Ralph, 1997) 10 It tells us that trauma is widespread Rosenberg and his colleagues from Dartmouth University who have done a good deal of research on people in the public mental health system found that 90% of these individuals have been exposed to trauma Goodman, in a separate study, found that 51-98% were exposed. Meuser and Felitti identified that most have had multiple experiences of various types of traumatic stress Homeless women are particularly vulnerable to rapeIt tells us that trauma is widespread Rosenberg and his colleagues from Dartmouth University who have done a good deal of research on people in the public mental health system found that 90% of these individuals have been exposed to trauma Goodman, in a separate study, found that 51-98% were exposed. Meuser and Felitti identified that most have had multiple experiences of various types of traumatic stress Homeless women are particularly vulnerable to rape

11. Prevalence of TraumaHomeless Population – Men More than 66% of men in a COD program for homeless people reported a history of trauma—either physical or sexual More than 25% of homeless men were assaulted in the past year Homeless men in SA treatment report high rates of depression, family dysfunction, and multiple tx experiences Homeless men are much less likely to be asked about trauma, yet alone services (Hopper, Bassuk, & Olivet, 2010) Note: The literature on men and trauma pales as compared to women/kids??? 11

12. Prevalence of TraumaMental Health Population - Children & Adolescents Canadian study of 187 adolescents reported 42% had PTSD (Kotlek, Wilkes, & Atkinson, 1998) American study of 100 adolescent inpatients; 93% had trauma histories and 32% had PTSD (Lipschitz et al, 1999) A study of one state system’s child/adolescent long-term care service-users (162) found 100% had documented trauma histories (Massachusetts DMH, 2007) 12 In terms of the prevalence of Post Traumatic Stress Disorder, the best defined and most clearly understood trauma diagnosis, among people with serious mental illness – In terms of the prevalence of Post Traumatic Stress Disorder, the best defined and most clearly understood trauma diagnosis, among people with serious mental illness –

13. Prevalence of TraumaHomeless Population – Women & Children 92% of homeless women report experiencing severe physical or sexual abuse; 60% before age 12 (HCS network, 1999) 63% of the above have experienced violence by intimate partners 65% of the sheltered homeless pop are women, women with families comprise 23% 50-60% experience homelessness proximal to fleeing a violent relationship 83% of children who have experienced violence have been victims or have observed significant violence including murder or attempted murder Homeless children as sick 4 times as often as other kids. (Prescott et al., 2008) 13

14. Prevalence of TraumaSubstance Abuse Population Up to two-thirds of men and women in SA treatment report childhood abuse & neglect (SAMSHA CSAT, 2000) Study of male veterans in SA inpatient unit 77% exposed to severe childhood trauma 58% history of lifetime PTSD (Triffleman et al, 1995) 50% of women in SA treatment have history of rape or incest (Gov. Comm. on Sexual and Domestic Violence, Comm. of MA, 2006) 14 Rosenberg and his colleagues from Dartmouth University who have done a good deal of research on people in the public mental health system found that 90% of these individuals have been exposed to trauma Goodman, in a separate study, found that 51-98% were exposed. Meuser and Felitti identified that most have had multiple experiences of various types of traumatic stress Homeless women are particularly vulnerable to rapeRosenberg and his colleagues from Dartmouth University who have done a good deal of research on people in the public mental health system found that 90% of these individuals have been exposed to trauma Goodman, in a separate study, found that 51-98% were exposed. Meuser and Felitti identified that most have had multiple experiences of various types of traumatic stress Homeless women are particularly vulnerable to rape

15. Prevalence of TraumaIncarcerated Women Framingham Women’s Prison, MA 90% receiving mental health services or substance abuse services have trauma histories (Governor’s Task Force, Comm. of MA., 2005) Correctional Institute for Women, RI 40% - Childhood sexual abuse 55% - Childhood physical abuse 53% - Adult rape 63% - Adult physical assault 34% - Lifetime PTSD (Zlotnick, 1997; Zlotnick, Najavits et al, 2003) 15 In terms of the prevalence of Post Traumatic Stress Disorder, the best defined and most clearly understood trauma diagnosis, among people with serious mental illness – In terms of the prevalence of Post Traumatic Stress Disorder, the best defined and most clearly understood trauma diagnosis, among people with serious mental illness –

16. Prevalence of TraumaIncarcerated Youth 93% males in a JJ facility reported a trauma history compared to 84% females (84%) - but more females met criteria for PTSD (18%/females, 11%/males) (Abram et al., 2004) 70% - 92% of incarcerated girls reported sexual, physical, or severe emotional abuse in childhood (DOC, 1998, Chesney & Sheldon, 1997) PTSD prevalence data varies widely: 3% to 50% in JJ settings and up to 8 times higher than community samples of same-age peers (Arroyo, 2001; Garland et al, 2001; Teplin et al, 2002;. Saigh et al, 1999, Saltzman et al, 2001) 16 In terms of the prevalence of Post Traumatic Stress Disorder, the best defined and most clearly understood trauma diagnosis, among people with serious mental illness – In terms of the prevalence of Post Traumatic Stress Disorder, the best defined and most clearly understood trauma diagnosis, among people with serious mental illness –

17. Trauma Prevalence The prevalence of trauma appears to be a link or “cross cutting principle” that affects people receiving services in all human service and healthcare settings These individuals often experience depressions, SA, serious mental conditions, vulnerability to re-victimization, difficulty working, impaired social networks (Hopper, Bassuk, & Olivet, 2010) 17

18. Pervasiveness of Trauma “In my own case, growing up in an alcoholic home, I came to accept chaos as a normal state of affairs rather than the exception. I wound up sabotaging my first marriage simply because the calm left me unsettled and nervous; I had to create chaos where none existed because that's all I was familiar with.”  - Suzanne Somers, actress & author 18

19. Well known & not-so-well known people aren’t immune from trauma Housewives’ star Teri Hatcher revealed she was sexually abused by her uncle after he was arrested for molesting another girl Many well known and not well known people have experienced trauma 19

20. What does all of this mean? Great question. A lot of really smart people are working on this answer…What we do know… Most of the people served in: MH/SA treatment settings have trauma histories DOC or juvenile justice systems have trauma histories Homeless systems have trauma histories Many people served in other care systems have experienced trauma (ID, TBI, Elderly) People who are not in care settings may also experience trauma – that means our staff, too (Hodas, 2004, Frueh et al, 2005; Mueser et al, 1998; Lipschitz et al., 1999; NASMHPD, 1998) 20 Traumatic exposure is epidemic among adults and children in the mental health system. Many clinicians in the US see PTSD as the only trauma-related diagnosis. Increasingly, we are appreciating that a range of other disorders can be directly related to trauma exposure or individuals might suffer from such co-occurring such as substance abuse, affective illness, personality disorders and psychotic disorders. Traumatic exposure is epidemic among adults and children in the mental health system. Many clinicians in the US see PTSD as the only trauma-related diagnosis. Increasingly, we are appreciating that a range of other disorders can be directly related to trauma exposure or individuals might suffer from such co-occurring such as substance abuse, affective illness, personality disorders and psychotic disorders.

21. Trauma: The interface between exposure, choices and health status Research has focused on the effects of childhood trauma on adult health outcomes: Adverse Childhood Experiences (The ACE Study) demonstrated the serious health consequences of trauma Increasing ACE scores correlated with the adoption of increasing numbers of risky health behaviors as coping mechanisms in adulthood, including: eating disorders, smoking, substance abuse, self harm, sexual promiscuity These behaviors resulted in: Severe medical conditions: heart disease, pulmonary disease, liver disease, STDs, GYN cancer, early death (Felitti, Anda et al, 1998) 21 Risk Behaviors developed as a coping response to trauma – alcohol to manage flashbacks, - can then put the person at greater risk..perpetuating the cycle of traumaRisk Behaviors developed as a coping response to trauma – alcohol to manage flashbacks, - can then put the person at greater risk..perpetuating the cycle of trauma

22. OK. So People who get services in public healthcare settings, are, most likely, trauma Survivors. So What? Calls for implementation of a TIC framework within our service settings. Just like in change theory, this is a multi step, staggered process that highlights three key areas of focus: Attitudes (of staff and clients) Implementation (how do we make changes?) Outcomes (how do we measure changes; may include quantitative or qualitative measures) (Hopper, Bassuk & Olivet, 2010) 22

23. Implementing TIC Attitudes: Programs trying to implement TIC have encountered resistance due to: Staff afraid of “ the Pandora’s box myth…” Lack of confidence in their ability to manage trauma reactions and their own Worry that they will not have enough resources to meet client needs Building staff buy-in is important and will take some time. This work requires “tireless leadership commitment”. It is also very rewarding. Clients have noted, in research studies, that staff who are empathic, caring, empowering and who offer “personal safety” are most effective. (Hopper et al., 2010) 23

24. Implementing TIC Implementation: Training on awareness of trauma and sensitivity training is key, for all staff. Ongoing and for first years, staff will require monitoring and mentoring to help them get up to speed on new practices. Staff involved will need to practice self care. Standardized screening tools are recommended for use in all agencies undertaking this work. Kids need to be included when serving families. More children, than adults will need trauma specific services. (Hopper et al., 2010) 24

25. Implementing TICImplementation: Know that implementing services that “are informed by trauma knowledge” will change your organization in terms of increasing sensitivity about the impact of trauma; require more freedoms and choices given to clients, and induce some environmental changes. Including people in recovery, as staff or consultants, is critical as it will change your system faster than more other interventions. For your services these would be ex-homeless people. (Hopper et al., 2010) 25

26. Implementing TICOutcomes: TIC service settings have better outcomes than “services as usual” for many symptoms and social issues and show a decrease in MH and SA symptoms/ improvement in engagement. Services that are Trauma Informed may have an improved and positive effect on housing stability (early research). Trauma Informed services may lead to a decrease in the use of crisis services and a loss of housing and inpatient care. Trauma Informed services are cost-effective. Clients respond better to Trauma Informed services. (Hopper et al., 2010) 26

27. Implementing TIC Starting Points: Do an organizational “self assessment” if you feel that you need to explore your agency’s readiness. Or “just do it.” Identify and use a theory based model to guide you. Document your org beliefs/vision in writing and train staff to these. Strive to avoid any practices that may be retraumatizing in your system. Implement universal trauma screening ,on admission, using standardized measures (Hopper et al., 2010) 27

28. Side bar: What if you don’t know if someone has a trauma history? What do you do? Staff in human service settings need to take a “universal precautions approach” Assume that everyone you serve has a history of trauma (Hodas, 2004) 28

29. Universal Precautions These kinds of ‘precautions’ are aimed at preventing illness or injury before they take place Like hand washing techniques to avoid passing on colds or using condoms for ‘safe sex’ In the Trauma Informed setting, this means using strategies to assure comfort, always be welcoming, avoid conflict/violence, meet needs assertively, and minimize any traumatic event that could hurt clients or staff (NETI, 2010) 29

30. Implementing TIC Starting Points: Program intake services should include a thorough assessment of client strengths and resources. Integrate SA, MH, and Trauma specific services. Programs must support and encourage consumer involvement. Include your clients in assessing and adapting your services. Have “trauma specific service” referrals at hand, especially for children. Be culturally and linguistically competent and use person first language. (Hopper et al., 2010) 30

31. What does this all mean? For the people we serve the outcomes of traumatic life experiences primarily means this: The loss of ability to regulate the intensity and duration of affect” (Schore, 2003) A breakdown in the capacity to regulate internal states including fear, anger, and sexual impulses” (van der Kolk, 2005) 31

32. The 3 Contexts of Healing: For Systems that are Trauma Informed Safety: A core developmental need for human beings. The defining experience of children or adults who have been traumatized is a pervasive mistrust of those “in power” whether these are parents, caretakers, providers, police or other officials. These people have suffered core damage to a early developmental stage called “trust vs. mistrust”. To bridge that, TIC systems have to first build trust. (Bath, 2008) 32

33. The 3 Contexts of Healing when systems are Trauma Informed Connections: The second pillar of Trauma Informed care expects the healthy development of relationships between service recipient and their care providers. These are life giving relationships that are required to bridge the distrust these victims bring to our systems of care. People who have experienced trauma bring suspicion, avoidance, and hostility to their relationships. It is what they expect. It is our role to change this. (Bath, 2008) 33

34. The 3 Contexts of Healing when systems are Trauma Informed Emotion and Impulse Management: The most pervasive impact of trauma is the dysregulation of emotions and impulses. The ability to regulate these are also one of the most “fundamental protective factors” for healthy adults. As such, all providers of human services need to understand the need to teach self regulation skills e.g. how to learn to “self sooth”. Active listening can help and labeling problem behaviors and their consequences is another step in this process. Practicing new strategies, with supervision, is key. (Bath, 2008) 34

35. What does a Trauma Informed Care System Look Like? 35

36. Uses interventions based on current literature and customer service principles Is informed by research and evidence of effective practice Recognizes that disrespect, shaming, coercion, or not meeting basic needs cause distress, traumatization and re-traumatization and are to be avoided 36 Seek to mitigate the effects of Trauma Fully consistent with person-center, recovery oriented careSeek to mitigate the effects of Trauma Fully consistent with person-center, recovery oriented care

37. Trauma Informed Non Trauma InformedHow would trauma be recognized? Recognition of high prevalence of trauma Life history is appreciated/recorded Recognition of setting/culture and practices that are re-traumatizing Lack of education on trauma prevalence & “universal” precautions Person seen without family/social history “Tradition of Toughness” valued as best care approach 37

38. A Trauma Informed Service Recognizes: “Any intervention that recreates aspects of previous traumatic experiences or that uses overt or covert power to punish is harmful to the individual involved” (NASMHPD, 1998) 38

39. Trauma Informed Non Trauma InformedHow would the service feel? Power/Control is minimized - constant attention to practices Language Counselors, Staff Caregivers/Supporters – Collaboration Address training needs of staff to improve knowledge, sensitivity, accessibility Staff demeanor, not being helpful, authoritative tone of voice Techs, Guards Rule Enforcers – Compliance “Client-blaming” as fallback position without training 39 Others know what is best – paternalistic model Self-injury – effective as a strategy for flashbacks, terror, numbing helps survivor regain control client who says it makes her feel strong instead of powerless hurt self instead of others trigger or stop dissociation convert emotional pain to physical pain Example about a woman’s experience. Complicated PTSD and Bipolar DO. Laura Prescott discussed the difference between a Trauma Informed vs trauma uninformed system Environment felt unsafe. Large men – loud voices – keys displayed – doors locked. This is a woman who had been locked in her room and repeatedly abused by her father. It is late evening, the time when she was typically abused. A staff member comes into the unit and yells to another staff person. Large man with keys on belt. Individual triggered – re-experience the abuse in her body feels unsafe. To manage - she finds a paper clip and starts digging into her skin. Three men jump on her to restrain her – put in four point restraints. Alternatively, gets triggered due to bedtime (internal trigger) – she starts to pace – the nurses approaches her to talk – she grabs a paperclip and starts to dig into her skin. Others know what is best – paternalistic model Self-injury – effective as a strategy for flashbacks, terror, numbing helps survivor regain control client who says it makes her feel strong instead of powerless hurt self instead of others trigger or stop dissociation convert emotional pain to physical pain Example about a woman’s experience. Complicated PTSD and Bipolar DO. Laura Prescott discussed the difference between a Trauma Informed vs trauma uninformed system Environment felt unsafe. Large men – loud voices – keys displayed – doors locked. This is a woman who had been locked in her room and repeatedly abused by her father. It is late evening, the time when she was typically abused. A staff member comes into the unit and yells to another staff person. Large man with keys on belt. Individual triggered – re-experience the abuse in her body feels unsafe. To manage - she finds a paper clip and starts digging into her skin. Three men jump on her to restrain her – put in four point restraints. Alternatively, gets triggered due to bedtime (internal trigger) – she starts to pace – the nurses approaches her to talk – she grabs a paperclip and starts to dig into her skin.

40. Trauma Informed Non Trauma InformedHow would people be respected? Understand function of behaviors (rage, apathy, irresponsibility, self-injury) Objective, neutral language Peer staff employees are present to assist other staff in understanding the person’s perspective Transparent systems open to outside parties Behavior seen as intentionally provocative & volitional Labeling language: manipulative, needy, gamey, “attention-seeking” Lack of Peer Supports Closed system – advocates discouraged 40 Others know what is best – paternalistic model Self-injury – “valiant attempts” (Sandy Bloom) at coping - effective as a strategy for flashbacks, terror, numbing helps survivor regain control client who says it makes her feel strong instead of powerless hurt self instead of others trigger or stop dissociation convert emotional pain to physical painOthers know what is best – paternalistic model Self-injury – “valiant attempts” (Sandy Bloom) at coping - effective as a strategy for flashbacks, terror, numbing helps survivor regain control client who says it makes her feel strong instead of powerless hurt self instead of others trigger or stop dissociation convert emotional pain to physical pain

41. Trauma Informed Non Trauma Informed What would you hear? Asking people how they prefer to be addressed “May I help you? What happened to you? Calling people by first name without permission or last name w/out title Ignoring the person who is clearly in need or stating “We will get to you when we have time….” “What is wrong with you?” 41 Others know what is best – paternalistic model Self-injury – effective as a strategy for flashbacks, terror, numbing helps survivor regain control client who says it makes her feel strong instead of powerless hurt self instead of others trigger or stop dissociation convert emotional pain to physical pain Focus on the Positive I can see how frustrated you are and it’s great you aren’t yelling.Others know what is best – paternalistic model Self-injury – effective as a strategy for flashbacks, terror, numbing helps survivor regain control client who says it makes her feel strong instead of powerless hurt self instead of others trigger or stop dissociation convert emotional pain to physical pain Focus on the Positive I can see how frustrated you are and it’s great you aren’t yelling.

42. Trauma Informed Non Trauma Informed What would you hear? Involving the individual in their own services and support decisions from the beginning. Taking the time to get to know everyone who comes into care. Encouraging them to speak about their personal story, needs, wishes and goals from their perspective. Practicing this with them Developing plans for services and supports without direct input from the person you are serving “Using documentation, instead of first hand knowledge to make decisions about people who are in care?” 42 Others know what is best – paternalistic model Self-injury – effective as a strategy for flashbacks, terror, numbing helps survivor regain control client who says it makes her feel strong instead of powerless hurt self instead of others trigger or stop dissociation convert emotional pain to physical pain Focus on the Positive I can see how frustrated you are and it’s great you aren’t yelling.Others know what is best – paternalistic model Self-injury – effective as a strategy for flashbacks, terror, numbing helps survivor regain control client who says it makes her feel strong instead of powerless hurt self instead of others trigger or stop dissociation convert emotional pain to physical pain Focus on the Positive I can see how frustrated you are and it’s great you aren’t yelling.

43. The Importance of Carefully Assessing Trauma 43

44. Why is Trauma Assessed? A more sensitive review of someone’s trauma history should be done respectfully and shortly after your first contact in order to: Identify past or current trauma, violence, abuse experiences Learn how trauma is expressed when the person is under duress Incorporate this information into an individualized, person-specific care plan Health care settings need to request this info from referral sources or do a short assessment themselves. (Cook et al, 2002; Fallot & Harris, 2002; Maine BDS, 2000) 44

45. Common Trauma Symptoms People Struggle With Dissociation Flashbacks Nightmares Hyper-vigilance Terror Anxiety Negative auditory hallucinations Numbness, Depression Substance abuse Self-injury Eating problems Sexual promiscuity Poor judgment and continued cycle of victimization 45 . People with traumatic exposure may have difficulty functioning within a level of optimal arousal and demonstrate symptoms of hypo or hyper arousal. Hypoarousal being demonstrated as numbing, dissociation, flattened affect, withdrawal, disconnection. Some of the hyperarousal sx demonstrate that continued emergency state of fight or flight include: flashbacks, terror, hypervigilance.. People with traumatic exposure may have difficulty functioning within a level of optimal arousal and demonstrate symptoms of hypo or hyper arousal. Hypoarousal being demonstrated as numbing, dissociation, flattened affect, withdrawal, disconnection. Some of the hyperarousal sx demonstrate that continued emergency state of fight or flight include: flashbacks, terror, hypervigilance.

46. Trauma Assessment Components Type sexual, physical, emotional, neglect, witnessed domestic violence, exposure to disaster, combat exposure, other Age When the abuse occurred is important in terms of the impact on the person’s development Who Was abuser a stranger? Family member? (Carmen et al, 1996) 46 (At end of entire slide) Someone who had a relatively stable life and was then raped at 22 will have had a before and after life changing event. But this is different from someone sexually abused by a parent consistently from an early age who may suffer from more a severe fragmentation of the self and the inability to become close to or trust another person.(At end of entire slide) Someone who had a relatively stable life and was then raped at 22 will have had a before and after life changing event. But this is different from someone sexually abused by a parent consistently from an early age who may suffer from more a severe fragmentation of the self and the inability to become close to or trust another person.

47. “The greater the power, the more dangerous the abuse.”  - Edmund Burke 47

48. Trauma Assessment: Key Principles Focus on “what happened to you” instead of “what is wrong with you” Begin to develop a therapeutic relationship (trust, respect, caring) during this process (Bloom, 2002) 48 Addresses context of the human experience rather than a pathology framework Addresses context of the human experience rather than a pathology framework

49. Trauma Assessment:Key Principles Information from the assessment and “positive responses” be incorporated into service plans or the assessment has no value Also, if previously disclosed, what happened? Ask if the person has ever told anyone, at all… 49 Young child in one of our programs was in a fire and spent entire inpatient stay playing with fire engine- helped in terms of assessment and treatment. At the beginning, dolls died in fire. By end, the firefighters were saving the dollsYoung child in one of our programs was in a fire and spent entire inpatient stay playing with fire engine- helped in terms of assessment and treatment. At the beginning, dolls died in fire. By end, the firefighters were saving the dolls

50. When Anne Heche Disclosed “I told my mother at about the seventh year of therapy that I had been abused sexually by my father, and she hung up the phone on me.” 50

51. In Summary… Most of the people who access public services have been traumatized When stressed, past trauma informs current behaviors Troubling behaviors can often be learned survival strategies Try to understand the consumer’s history and how to support efforts to teach self-calming and regaining control Practices that take away control and choice can be traumatizing Watch for trauma “uninformed” practices and try to prevent, avoid or eliminate these Keep asking – is what I am doing respectful and trauma-informed? Is it how I would like to be treated? 51

52. “If you can, help others; if you cannot do that, at least do not harm them.” - Dalai Lama “Kindness is a language that the deaf can hear and the blind can see.” - Mark Twain In 35 years of nursing I have learned one thing, for sure. And that is that no matter how ill or disorganized someone is, they know if you care about them. Or not. Kevin H 52

53. Contact Information Joan.gillece@nasmhpd.org NCTSN.org www.homless.samhsa.gov www.nasmhpd.org Kevin Huckshorn RN, MSN, CADC DSAMH 302-255-9398 kevin.huckshorn@state.de.us 53