Understanding and Implementing Trauma Informed Care:

1. Understanding and Implementing Trauma Informed Care: Treatment and impact of trauma on persons with mental illness and co-occurring disorders

2. Overview of today’s presentation • Trauma defined • Acute/Chronic Stress and Trauma • Causal Factors • Response to Trauma (as a patient as a clinician) • Impact of Trauma on Addictions • Difference in treatment and assessment (the nuances of symptoms) • Resilience and protective factors • Treatment alternatives with Trauma • Trauma and 12 Step program

3. Welcome: starting with basic housekeeping items Introduction/overview and presentation breaks Presentation Wrap-up/Q&A

4. Our takeaway for today: • A working definition of Acute, Chronic Stress and Trauma. • Understand the importance of developing a safe, calm and secure environment with supportive care to ensure the physical and emotional safety of persons served by the organization • understanding of trauma prevalence; importance of resilience and protective factors • The impact of Trauma and co-mingling of substance abuse/addictions. • Recovery, consumer-driven and trauma specific services and treatments(Empowerment) • Care for the Caregiver

5. Getting to know you • Introductions/Experience/History • Who do we have in the audience

6. Trauma Defined • Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects on the individual's functioning and physical, social, emotional, or spiritual well-being

7. 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.” NCTIC, SAMHSA

8. Types of Trauma

9. Acute Trauma: Complex Trauma:

10. Chronic Trauma: System Induced Trauma:

11. Causal Factors of Trauma Family – parents, siblings, grandparents, aunts and uncles. Good friends of parents (who is family these days?) Friends – school, sports, extra curricular activities Peers – school, sports, workmates Environmental – hurricane, floods, fire *social networking

12. Prevalence of TraumaMental Health Population – United States • 90% of public mental health clients involved in Mental Health treatment have been exposed to trauma (Mueser et al., 2004, Mueser et al., 1998) • 51-98% of public mental health clients in have been exposed to trauma (Goodman et al., 1997, Mueser et al., 1998) • Most Mental Health Clients have multiple experiences of trauma (Mueser et al., 2004, Mueser et al., 1998) • 97% of homeless women with SMI have experienced severe physical & sexual abuse – and of that 97% it has been determined that 87% experience this abuse both in childhood and adulthood (Goodman et al., 1997)

13. Prevalence Continued According to the U.S. Department of Health and Human Services Office on Women’s Health, 55% – 99% of women in substance use treatment and 85% – 95% of women in the public mental health system report a history of trauma, with the abuse most commonly having occurred in childhood. National Council for Behavioral Health

14. Nuances of Symptoms: Depression Anger Anxiety Inattentive Cutting Suicidal Delusional Disorientation

15. “We have learned, given the numbers of trauma survivors and their often debilitating post-traumatic responses, that this constitutes a public health challenge of the first magnitude.” Susan Salasin, SAMHSA

16. The human story… …is a story of strength, adaption and resilience.

17. Impact of Toxic Stress on the Brain Center of Children: Center for Developing Child, Harvard University

18. Trauma – an intense event that threatens safety or security of an individual Toxic Stress – re-occurring negative experiences that threaten safety or security

19. Lunch Break

20. Resilience, Stress, and Trauma

21. Resilience and Protective Factors • Sharon

22. Treatment for Trauma: Focusing on Strength And Viewing the Entire picture

23. Starting with a strength based assessment

24. What Makes it Hard to Focus on Strengths? • Natural reactions to negative conditions and effects • Assessment, planning, service, reimbursement systems based on deficits (diagnoses, symptoms) • Challenging behaviors that accompany some common post-trauma conditions • Human tendency to stigmatize • Fear

25. But if We Can focus on Strength we can; • Affirm the dignity of all people • Take people from “victim” to survivor—to hero • Generate hope • Make it safe to claim the power of choice and healthy social connection • Protect, nourishes, empowers • Make it safe for the story to be told

26. As Clinicians imagine if we could: • change the way we ask questions; Instead of asking “What happened to you?” instead of “What is wrong with you? • Be aware and understand that the past trauma can be triggered by experiences in the present • That we are supporting people as they heal • Leaves a person feeling edified

27. Looking at the Whole Continuum

28. Looking at the Whole Challenge • Toxic stress and trauma • Environmental, family, and individual factors • Multiple stressful/traumagenic experiences • Multiple effects, multiple behavioral reactions • Multiple types of challenges and disorders

29. Multiple Traumagenic Experiences Historical Trauma In Communities, Families, Lives Child Neglect & Abuse Vicarious Trauma Disaster Trauma Domestic Violence Traumatic Loss & Grief Self Military Trauma Family Community Violence Medical Trauma Community Poverty, Racism, Hopelessness Trauma in CJ & Treatment Great Lakes ATTC

30. The Power of Human Connection Great Lakes ATTC

31. The Whole Picture: Collaboration Among • Multiple systems (e.g., mental health, substance use disorders, prevention, medicine, criminal justice, child welfare, education) • Multiple community resources (e.g., civic orgs., communities of recovery, faith communities, natural helpers, cultural healers, AA) • Multiple approaches linked by supportive screening and referral networks, for a “no wrong door” approach Great Lakes ATTC

32. A Place for Everyone Community & Civic Groups First Responders Multiple Systems, Constituents, Efforts Child Welfare Natural Helpers in Neighborhood Juvenile Justice Faith Communities, Spiritual Leaders Self Natural “listeners” in Community Medical Systems, Cultural Healers Family Treatment & Recovery Schools and School Staff Community Child Care & Senior Services Shelters, Food Programs, etc. Business & Philanthropy Great Lakes ATTC

33. Breaking it Down

34. Great Lakes ATTC Dahlgren & Whitehead, 2010 DETERMINE Final Report

35. Isolation, Resources absent or wasted Connection, Resources found & used wisely Great Lakes ATTC

36. The Impact of the ACES study

37. Adverse Childhood Experiences (ACE) Study • Co-PIs: Robert F. Anda, MD (CDC) and Vincent J. Feltti, MD (Kaiser Permanente) • HMO enrollees, average age 59, interviewed about difficult childhood experiences • More than 17,000 interviewed, data still being analyzed • Staggering results, many since replicated • Start with: www.acestudy.org

38. Reports of ACEs, First Round of the Study • The Adverse Childhood Experiences, or “ACE” Study has done more than anything to measure the long-term consequences of childhood trauma and put them “on the map.” It started with a simple question that one of the Co-PIs, Dr. Vincent Felitti, asked a woman who was struggling in his weight-loss program. Her answer revealed some unexpected connections between child trauma and later-life illness, and set him and Dr. Robert Anda, who would become his Co-PI, on an incredible journey.

39. Reports of ACEs, First Round of the Study

41. Great Lakes ATTC Washington State Family Policy Council, based on ACE Study data.

43. Internal Environment Great Lakes ATTC

44. The Illness End of the Spectrum Includes • Posttraumatic stress disorder • Depressive (e.g., bipolar) and anxiety disorders • Substance use disorders • Personality disorders, conduct disorders • Psychotic disorders, including schizophrenia • Immune, autoimmune disorders • Cardiovascular, pulmonary disorders • Gastrointestinal, metabolic disorders Great Lakes ATTC

45. Traditional Human Service Paradigm • Hierarchical: Rule, control, and manage • “Blame the victim” or consider people helpless • Focus on problems; see behaviors as symptoms • See as individual problems; ignore environment • Separate service systems, minimal coordination • Emphasize individual diagnoses • Treat “separate” conditions separately Great Lakes ATTC

46. Stages of Trauma Recovery(Judith Herman) Great Lakes ATTC

47. Work group on Addiction and Recovery • Using the three steps identified in Trauma Recovery, discuss and report how these same three steps are found in Substance Abuse Recovery • In each stage what are factors that could impact recovery at each stage: • First review trauma • Then review with SA

48. Stage-appropriate Treatment Stage 3: Reconnection Stage 2: Remembrance & Mourning Additional Models Stage 1: Safety & Stabilization Trauma-focused Treatment Trauma-informed Care

49. SAMHSA’s Key Principles for TIC • Safety: Setting and interactions physically and psychologically safe • Trustworthiness and Transparency: Meaningful sharing of power and decision making; Trans- parent operations/decisions maintain trust • Collaboration/Mutuality: Partnership, leveling of power differences; Recognition that healing happens in relationships and in meaningful sharing of power

50. SAMHSA’s Key Principles (Cont’d.) • Empowerment: Individuals’ strengths are recognized, built on, validated; New skills built as necessary • Voice and Choice: Aim is to strengthen staff’s, participants, families’ experience of choice; Recognition of need for individualized approach • Inclusiveness and Shared Purpose: everyone has a role to play; Don’t have to be a therapist to be therapeutic Great Lakes ATTC