Understanding the Effects of Trauma

1. Understanding the Effects of Trauma Presented By: Brian Sims, MD National Association of State Mental Health Program Directors, National Technical Assistance Center

2. Lateral Ventricles Measures in an 11 Year Old Maltreated Male with Chronic PTSD, Compared with a Healthy, Non-Maltreated Matched Control This slide demonstrates the physical impact of trauma on the brain. This work comes from an important study by Dr. Michael DeBellis (pronounced: Bayless with a long �a�) and his colleagues that was published in Biological Psychiatry in 1999. Dr. DeBellis studied the brains of children who were abused and compared them to the brains of children who were not abused. Dr. DeBellis found that the brains of children who had been abused were different. (Again, it might be helpful to use a laser pointer here.) If you look on the left side, the healthy child�s brain, you see a thin external layer covering the brain (white area arching over brain image). If you look at the image on the right, you see a thicker white band. This shows atrophy or shrinkage of the cerebral cortex. Besides the cortex, other structures of the brain change, like the hippocampus and the amygdala. These structures also decrease in size. But the lateral ventricles, on the other hand, increase in size in people who are traumatized. See this black triangle shapes on left image and how much larger they are in the MRI image of the child with trauma on the right? Trauma physically effects the brain and how it functions. Karestan Koenen, a researcher from Boston, published a groundbreaking twin study in 2003. She looked at twins who were discordant for trauma, meaning one had a history of trauma and one did not. What she found was that the twin who had a trauma history, had on average, an 8-point reduction in IQ scores � the only distinguishing variable was the trauma. Lowered IQ is a significant risk factor for other negative outcomes, like school failure and juvenile delinquency. What this means is that people with trauma histories, can also have brains that have been adversely effected by that experience. So, trauma can directly effect learning and day-to-day functioning of the people we serve, for the rest of their lives. This slide demonstrates the physical impact of trauma on the brain. This work comes from an important study by Dr. Michael DeBellis (pronounced: Bayless with a long �a�) and his colleagues that was published in Biological Psychiatry in 1999. Dr. DeBellis studied the brains of children who were abused and compared them to the brains of children who were not abused. Dr. DeBellis found that the brains of children who had been abused were different. (Again, it might be helpful to use a laser pointer here.) If you look on the left side, the healthy child�s brain, you see a thin external layer covering the brain (white area arching over brain image). If you look at the image on the right, you see a thicker white band. This shows atrophy or shrinkage of the cerebral cortex. Besides the cortex, other structures of the brain change, like the hippocampus and the amygdala. These structures also decrease in size. But the lateral ventricles, on the other hand, increase in size in people who are traumatized. See this black triangle shapes on left image and how much larger they are in the MRI image of the child with trauma on the right? Trauma physically effects the brain and how it functions. Karestan Koenen, a researcher from Boston, published a groundbreaking twin study in 2003. She looked at twins who were discordant for trauma, meaning one had a history of trauma and one did not. What she found was that the twin who had a trauma history, had on average, an 8-point reduction in IQ scores � the only distinguishing variable was the trauma. Lowered IQ is a significant risk factor for other negative outcomes, like school failure and juvenile delinquency. What this means is that people with trauma histories, can also have brains that have been adversely effected by that experience. So, trauma can directly effect learning and day-to-day functioning of the people we serve, for the rest of their lives.

3. What is Trauma? Definition (NASMHPD, 2004): The personal experience of interpersonal violence including sexual abuse, physical abuse, severe neglect, loss, and/or the witnessing of violence, terrorism, and disasters. In trauma informed care systems, we want to integrate these principles into all our clinical interventions. We want to include the survivor�s perspective. That�s so important as we move from our controlling environments, to collaborative supported environments. We recognize that coercive interventions are contraindicated for people who have been abused. It is re-traumatizing and recapitulates victimization. In trauma informed care systems, we want to integrate these principles into all our clinical interventions. We want to include the survivor�s perspective. That�s so important as we move from our controlling environments, to collaborative supported environments. We recognize that coercive interventions are contraindicated for people who have been abused. It is re-traumatizing and recapitulates victimization.

4. What is trauma Events/experiences that are shocking, terrifying, and/or overwhelming to the individual. Results in feelings of fear, horror, helplessness

5. Types of trauma resulting in serious and persistent mental health problems: Are interpersonal in nature: intentional, prolonged, repeated, severe Occur in childhood and adolescence and may extend over an individual�s life span (Terr, 1991; Giller, 1999) For our purposes, when we refer to trauma, we are not referring to a single isolated event. We speak of trauma in terms of interpersonal events that are intentional and severe. They are frequently repeated and prolonged. The traumatic experiences normally occur in childhood and adolescence. The patterns of abuse may extend into adulthood and we are now recognizing similar experiences in the elderly.For our purposes, when we refer to trauma, we are not referring to a single isolated event. We speak of trauma in terms of interpersonal events that are intentional and severe. They are frequently repeated and prolonged. The traumatic experiences normally occur in childhood and adolescence. The patterns of abuse may extend into adulthood and we are now recognizing similar experiences in the elderly.

6. What does trauma do? Symptoms are ADAPTATIONS Trauma shapes a child�s basic beliefs about identity, world view, and spirituality. Using a trauma framework, the effects of trauma can be addressed and a person can go on to lead a �productive� life. (Saakvitne, Gamble, Pearlman & Lev, 2000. Risking Connection� (Sidran Press), p. 12)

7. Consequences of trauma Faulty control methods: Over-control Self-blame Passivity Addictive behavior Self-harm Impaired attachments: Warmth by friction Interpersonal skill deficits

8. Self Inflicted Injuries People use self-harm because it helps them manage what feels unbearable in the moment. There is a great deal of intensity behind the acts of self-injury. Feeling states such as profound despair, anguish, rage or terror, or a fear of losing oneself or being swallowed by traumatic flashbacks or re-enactments are just some of the stressors leading to self-inflicted violence (SIV). (Mazelis, Self-Inflicted Violence FAQ, www.healingselfinjury.org)

9. Self Inflicted Injuries Although inaccurate, it is commonly believed that people self-injure in a simplistic and manipulative way to get attention from others. While the wounds of SIV are often upsetting to others and do attract attention, many people who live with SIV keep this a secret. The attention one receives for self-injury is rarely a compassionate response. (Mazelis, Self-Inflicted Violence FAQ, www.healingselfinjury.org)

10. Self Inflicted Injuries People are often shamed for self-injury; sometimes people are institutionalized if the behavior is misinterpreted as a suicide attempt. Those seeking medical care are sometimes chastised and it is not unheard of for people who seek help for cuts to be stitched without the use of anesthetic. (Mazelis, Self-Inflicted Violence FAQ, www.healingselfinjury.org)

11. Why do People Self Harm? Help diminish intense emotional or psychic pain that might be of such intensity that one is considering suicide Help people discover or reconnect with their own physical boundaries Help survivors manage feelings of terror or rage, whether the anger is felt towards oneself or someone else. Can diminish intense anxiety or feelings of unbearable stress (Mazelis, The Cutting Edge, Vol. 15, Issue 1(57))

12. Why do People Self Harm? A way that previous abuse can be re-enacted on one�s own body in an attempt to manage and understand the past Can serve to stop �flashbacks� of trauma Serves as a means of communication when words do not feel sufficient or available. (Mazelis, The Cutting Edge, Vol. 15, Issue 1(57))

13. Dissociation A mental process which produces a lack of connection in a person�s thoughts, memories, feelings, actions, or sense identity. During dissociation certain information is not associated with other information as it normally would be. For example: during a traumatic experience, a person may dissociate the memory of the place and circumstances of the trauma from his ongoing memory, resulting in a temporary mental escape from the fear and pain of the trauma and, in some cases, a memory gap surrounds the experience. (What is a Dissociative Disorder?, Sidran Institute, www.sidran.org )

14. Post-Traumatic Stress Disorder (PTSD) Symptoms of PTSD Intrusive Re-experiencing Avoidance Arousal (What is PTSD?, Sidran Institute, www.sidran.org)

15. Intrusive Re-experiencing People with PTSD frequently feel as if the trauma is happening again. This is may be called a flashback, reliving experience, or abreaction. The person may have intrusive pictures in his/her head about the trauma, have recurrent nightmares, or may even experience hallucinations about the trauma. (What is PTSD?, Sidran Institute, www.sidran.org)

16. Intrusive Re-experiencing Intrusive symptoms sometimes cause people to lose touch with the "here and now" and react in ways that they did when the trauma originally occurred. For example, many years later a victim of child abuse may hide trembling in a closet when feeling threatened, even if the perceived threat is not abuse-related. (What is PTSD?, Sidran Institute, www.sidran.org)

17. Avoidance People with PTSD work hard to avoid anything that might remind them of the traumatic experience. They may try to avoid people, places or things that are reminders, as well as numbing out emotions to avoid painful, overwhelming feelings. Numbing of thoughts and feelings in response to trauma is known as "dissociation" and is a hallmark of PTSD. Frequently, people with PTSD use drugs or alcohol to avoid trauma-related feelings and memories. (What is PTSD?, Sidran Institute, www.sidran.org)

18. Arousal Symptoms of psychological and physiological arousal are very distinctive in people with PTSD. They may be very jumpy, easily startled, irritable and may have sleep disturbances like insomnia or nightmares. They may seem constantly on guard and may find it difficult to concentrate. Sometimes persons with PTSD will have panic attacks accompanied by shortness of breath and chest pain. (What is PTSD?, Sidran Institute, www.sidran.org)

19. Traumatized children have the dilemma of having experienced both the overwhelming arousal of abuse and the absence of adequate soothing and comforting. Thus, they are often in a state of hyper-arousal and are particularly unskilled at self-soothing (self-regulation). (Saakvitne, Gamble, Pearlman & Lev, 2000.Risking Connection� (Sidran Press), p. 19)

20. Trauma and Attachment Trauma that happens in childhood at the hands of caregivers is doubly destructive because it destroys the attachment relationship that the child would normally need to depend on to manage the trauma of the abuse. The resolution of attachment issues is a central component of trauma treatment. (Saakvitne, Gamble, Pearlman & Lev, 2000.Risking Connection� (Sidran Press), p. 19)

21. The growth of self regulation is a cornerstone of early development that cuts across all behavioral domains. (Shonkoff & Phillips, 2000) from the Neurons to Neighborhoods report, the second basic core concept stresses the importance of self-regulation. Our focus has to include helping people learn how to control their emotional and behavioral states. With respect to trauma, one of the most important concepts to understand is what happens when that experience is triggered and there is a transition from �calm and continuous states� to �discrete states of emergency.� from the Neurons to Neighborhoods report, the second basic core concept stresses the importance of self-regulation. Our focus has to include helping people learn how to control their emotional and behavioral states. With respect to trauma, one of the most important concepts to understand is what happens when that experience is triggered and there is a transition from �calm and continuous states� to �discrete states of emergency.�

22. Here is an example of this transition. This is a slide that depicts what happened with a young man named Robert. Robert was severely physically abused by his stepfather on a regular basis. He was on a psychiatric unit and he was actually having a good day; everything was going great for Robert. Then he perceived that a male staff member said something demeaning to him. What happened? He immediately went from a calm, continuous state to a state of aggression. He lunged at the staff member. What happens when you lunge at a staff member? You get restrained. Robert was restrained and then he started to re-experience the physical abuse he suffered as a child. He began to dissociate and lose all sense of reality. What was discovered afterwards, through meticulous debriefing, was that when he overheard the staff person say something, he heard it in his stepfather�s tone of voice. Robert perceived it as demeaning. So, he went from a calm, continuous state to three extreme states of emergency. The transition between calm and continuous states and discrete states of emergency are fundamental for understanding trauma and how the brain responds to perceived threat and stress. Here is an example of this transition. This is a slide that depicts what happened with a young man named Robert. Robert was severely physically abused by his stepfather on a regular basis. He was on a psychiatric unit and he was actually having a good day; everything was going great for Robert. Then he perceived that a male staff member said something demeaning to him. What happened? He immediately went from a calm, continuous state to a state of aggression. He lunged at the staff member. What happens when you lunge at a staff member? You get restrained. Robert was restrained and then he started to re-experience the physical abuse he suffered as a child. He began to dissociate and lose all sense of reality. What was discovered afterwards, through meticulous debriefing, was that when he overheard the staff person say something, he heard it in his stepfather�s tone of voice. Robert perceived it as demeaning. So, he went from a calm, continuous state to three extreme states of emergency. The transition between calm and continuous states and discrete states of emergency are fundamental for understanding trauma and how the brain responds to perceived threat and stress.

23. Here�s another example; this involves a 12 year old girl named Talia. She had a history of sexual abuse, but she was living at home and going to school in the community. Talia was in school that day and having a good day. She was sitting in math class and the boy next to her made a demeaning comment about her breasts. So, here was Talia in a calm and continuous state; a male peer made a demeaning comment about her breasts and she immediately began to feel this intense sense of shame. She got up from her desk and walked out of the classroom. After Talia walked out of the classroom she felt even more shame and she began to feel like she was being raped again � actually, in her mind, re-experiencing the rape. She walked out of the school and began to walk home, since she lived close by. This sequence of events was determined through meticulous interviewing/debriefing after the event. Talia walked home; opened the front door and went into the bathroom. She took out a knife that she hid in the medicine cabinet and began to cut herself and dissociate. Luckily Talia�s Mother was home and immediately took her to the hospital for treatment. But, this is another example where self-regulation did not occur � self-regulation is the second cornerstone. She went from a calm, continuous state, to the boy saying something demeaning, to feeling shame, fear, then dissociation � with no capacity to control her behavior and feelings. Here�s another example; this involves a 12 year old girl named Talia. She had a history of sexual abuse, but she was living at home and going to school in the community. Talia was in school that day and having a good day. She was sitting in math class and the boy next to her made a demeaning comment about her breasts. So, here was Talia in a calm and continuous state; a male peer made a demeaning comment about her breasts and she immediately began to feel this intense sense of shame. She got up from her desk and walked out of the classroom. After Talia walked out of the classroom she felt even more shame and she began to feel like she was being raped again � actually, in her mind, re-experiencing the rape. She walked out of the school and began to walk home, since she lived close by. This sequence of events was determined through meticulous interviewing/debriefing after the event. Talia walked home; opened the front door and went into the bathroom. She took out a knife that she hid in the medicine cabinet and began to cut herself and dissociate. Luckily Talia�s Mother was home and immediately took her to the hospital for treatment. But, this is another example where self-regulation did not occur � self-regulation is the second cornerstone. She went from a calm, continuous state, to the boy saying something demeaning, to feeling shame, fear, then dissociation � with no capacity to control her behavior and feelings.

24. Parameters that change between state Affect Thought Behavior Sense-of-self Consciousness If you think about either of these examples � there was a triggering event that lead to a dramatic change in behavior. Think of Robert on the unit - he was feeling good just beforehand, and afterwards, he was rageful. He was thinking about himself before as �I�m fine, I�m doing well� and after that triggering statement by the staff he was dramatically different. His behavior was obviously different; as was his sense of himself. He lost control of himself. There were dramatic shifts in all of these areas as well. If you think about either of these examples � there was a triggering event that lead to a dramatic change in behavior. Think of Robert on the unit - he was feeling good just beforehand, and afterwards, he was rageful. He was thinking about himself before as �I�m fine, I�m doing well� and after that triggering statement by the staff he was dramatically different. His behavior was obviously different; as was his sense of himself. He lost control of himself. There were dramatic shifts in all of these areas as well.

25. Goal of Treatment Maintain Calm/Continuous/Engaged State Prevent Discontinuous States Build Cognitive Structures that allow choices So, the goal of treatment is to help people to maintain calm and continuous engaged states; to prevent discontinuous states; and to build cognitive structures that allow choices. This is important � this is how we want to set up our treatment environments � to help the people we serve learn how to maintain calm states, prevent discontinuous states, and build cognitive structures. So, the goal of treatment is to help people to maintain calm and continuous engaged states; to prevent discontinuous states; and to build cognitive structures that allow choices. This is important � this is how we want to set up our treatment environments � to help the people we serve learn how to maintain calm states, prevent discontinuous states, and build cognitive structures.

26. The following slides actually illustrate this transition process. In this case, you have a stimulus, it could be any stimulus. It could be Robert on the unit who hears his stepfather�s voice; it could be Talia at school who hears the negative comment about her breast. In both cases, they go from stimulus to response without thinking. The following slides actually illustrate this transition process. In this case, you have a stimulus, it could be any stimulus. It could be Robert on the unit who hears his stepfather�s voice; it could be Talia at school who hears the negative comment about her breast. In both cases, they go from stimulus to response without thinking.

27. We divide potentially successful interventions into two types: the first are neuroregulatory interventions. These are the interventions that help the individual to have the capacity to soothe themselves, to calm themselves, to regulate their emotions between emotional and behavioral states. Remember, people who are traumatized have deficits - sometimes big deficits - in their ability to regulate their emotions. The second intervention is the social environment. This is just as important. On our units, we do have some control over how we set up the social environment. What Dr. Glenn Saxe did in his unit was ask each of the adolescents he served, in careful detail, about what was trigged or stimulated them so that staff could adjust the unit environment and reduce the source or sense of threat. We divide potentially successful interventions into two types: the first are neuroregulatory interventions. These are the interventions that help the individual to have the capacity to soothe themselves, to calm themselves, to regulate their emotions between emotional and behavioral states. Remember, people who are traumatized have deficits - sometimes big deficits - in their ability to regulate their emotions. The second intervention is the social environment. This is just as important. On our units, we do have some control over how we set up the social environment. What Dr. Glenn Saxe did in his unit was ask each of the adolescents he served, in careful detail, about what was trigged or stimulated them so that staff could adjust the unit environment and reduce the source or sense of threat.

28. To further highlight this point, let�s consider two important structures in the brain. (Use a laser pointer or just point to the area of the brain here) This part is called the amygdala. It is responsible for fight or flight, we all have an amygdala. Another part of the brain is the hippocampus, which is here - above the amygdala. The hippocampus applies context to the situation and helps to regulate the amygdala and other functions in the brain. To further highlight this point, let�s consider two important structures in the brain. (Use a laser pointer or just point to the area of the brain here) This part is called the amygdala. It is responsible for fight or flight, we all have an amygdala. Another part of the brain is the hippocampus, which is here - above the amygdala. The hippocampus applies context to the situation and helps to regulate the amygdala and other functions in the brain.

29. Let�s walk through how the brain operates. A stimulus occurs; it could be any stimulus. It could be the young man, Robert, who hears his stepfather saying something demeaning.Let�s walk through how the brain operates. A stimulus occurs; it could be any stimulus. It could be the young man, Robert, who hears his stepfather saying something demeaning.

31. The stimulus is transmitted very quickly to the amygdala. The amygdala is built for survival. It is an immediate response; you do not even think about it; it just happens. The stimulus is transmitted very quickly to the amygdala. The amygdala is built for survival. It is an immediate response; you do not even think about it; it just happens.

32. Then, split seconds later, the same stimulus is relayed to the cortex and the hippocampus. This is where memory and context come into play. Then, split seconds later, the same stimulus is relayed to the cortex and the hippocampus. This is where memory and context come into play.

33. So, let�s say for example, all of a sudden the door in the back of this auditorium slams shut. What do you do? You jump. Maybe; you get sweaty for a minute, you might begin to slightly move your body as if you were going to get up and run out. That is your amygdala reacting to the sound stimulus. But immediately afterwards, your cortex and your hippocampus translate the stimulus and you say, �Wait a minute; I�m sitting in this room; I haven�t been hurt by sitting in an auditorium and a door slamming.� So, you relax and get back to the training. Your response is to relax again.So, let�s say for example, all of a sudden the door in the back of this auditorium slams shut. What do you do? You jump. Maybe; you get sweaty for a minute, you might begin to slightly move your body as if you were going to get up and run out. That is your amygdala reacting to the sound stimulus. But immediately afterwards, your cortex and your hippocampus translate the stimulus and you say, �Wait a minute; I�m sitting in this room; I haven�t been hurt by sitting in an auditorium and a door slamming.� So, you relax and get back to the training. Your response is to relax again.

34. But let�s say we�re at the Empire State Building in New York City and we�re sitting on the 80th floor in this same training and we hear this very loud bang. What happens to those people in New York on the 80th floor now � after 9/11? They might just run out of the room not only because their amygdala is activated but because the context created by hippocampus has changed since the 9/11 tragedy. But let�s say we�re at the Empire State Building in New York City and we�re sitting on the 80th floor in this same training and we hear this very loud bang. What happens to those people in New York on the 80th floor now � after 9/11? They might just run out of the room not only because their amygdala is activated but because the context created by hippocampus has changed since the 9/11 tragedy.

35. So what happens is that we have an IMMEDIATE response. This is what happens to people with traumatic stress. Their amygdala is activated, their capacity to wait for the �context� is diminished and they respond rapidly to a perceived threat or emergency and shift into an �emergency state of behavior�. So what happens is that we have an IMMEDIATE response. This is what happens to people with traumatic stress. Their amygdala is activated, their capacity to wait for the �context� is diminished and they respond rapidly to a perceived threat or emergency and shift into an �emergency state of behavior�.

36. What else happens? The structures of the brain can be altered by trauma. The cortex can shrink. The amygdala can decrease in volume and the hippocampus can atrophy. The structures and function of the brain is changed. What else happens? The structures of the brain can be altered by trauma. The cortex can shrink. The amygdala can decrease in volume and the hippocampus can atrophy. The structures and function of the brain is changed.

37. So, to help the traumatized people we serve, we need to build in structures to help them regulate their emotions and behavior. One way, is to create neuroregulatory interventions. Some researchers believe that the common pathway of many of the agents that we use is to diminish the amygdala from responding. We can also help trauma survivors by creating social environmental interventions, and cognitive behavioral and social skill approaches. We can survey the environment to reduce factors that may contribute to distress and also work to enhance emotional processing interventions. We need to create environments where behavior is anticipated and not reacted to. So, to help the traumatized people we serve, we need to build in structures to help them regulate their emotions and behavior. One way, is to create neuroregulatory interventions. Some researchers believe that the common pathway of many of the agents that we use is to diminish the amygdala from responding. We can also help trauma survivors by creating social environmental interventions, and cognitive behavioral and social skill approaches. We can survey the environment to reduce factors that may contribute to distress and also work to enhance emotional processing interventions. We need to create environments where behavior is anticipated and not reacted to.

38. Play

39. These are rats that live in a laboratory. They have never been out of the laboratory. Dr. Panksepp keeps track of how often they play. Basically, they play all of the time. They are born; they have this wonderful life; they live in a cage in a laboratory and they play, play, play. So what he did was put a �minimal fear stimulus,� a single cat hair in their cage. Just one cat hair. Mind you, these are rats have never seen a cat. He put one cat hair inside their cage and what do you think happened? They stopped playing completely. The cat hair was in the cage for 24 hours; and they did not play for 24 hours. But what was even scarier, when he took the cat hair out, the rats never played the same amount of time again in their lives. So, one cat hair for 24 hours caused lifelong changes to playing behavior. When you think about the people we serve, some of them come from homes that are full of cat hair, some live with the cat. Some of them have lived in environments that are full of cat hair and what we want to make sure is that our units are not full of cat hair. These are rats that live in a laboratory. They have never been out of the laboratory. Dr. Panksepp keeps track of how often they play. Basically, they play all of the time. They are born; they have this wonderful life; they live in a cage in a laboratory and they play, play, play. So what he did was put a �minimal fear stimulus,� a single cat hair in their cage. Just one cat hair. Mind you, these are rats have never seen a cat. He put one cat hair inside their cage and what do you think happened? They stopped playing completely. The cat hair was in the cage for 24 hours; and they did not play for 24 hours. But what was even scarier, when he took the cat hair out, the rats never played the same amount of time again in their lives. So, one cat hair for 24 hours caused lifelong changes to playing behavior. When you think about the people we serve, some of them come from homes that are full of cat hair, some live with the cat. Some of them have lived in environments that are full of cat hair and what we want to make sure is that our units are not full of cat hair.

40. Definition of TraumaInformed Care Services that are directed by: a thorough understanding of the profound neurological, biological, psychological and social effects of trauma and violence on the individual and an appreciation for the high prevalence of traumatic experiences in persons who receive mental health services (Jennings, 2004) Trauma informed services can be provided in most social service settings. Homeless shelters, substance abuse programs, mental health facilities as well as juvenile and adult correctional settings all benefit from systems that understand the prevalence and effects of trauma in the populations they serve. Trauma informed systems of care are systems where precautions are in place to prevent future re-tramatization .Trauma informed services can be provided in most social service settings. Homeless shelters, substance abuse programs, mental health facilities as well as juvenile and adult correctional settings all benefit from systems that understand the prevalence and effects of trauma in the populations they serve. Trauma informed systems of care are systems where precautions are in place to prevent future re-tramatization .

41. Reported Prevalence of TraumaMental Health Population 90% of public mental health clients have been exposed (Mueser et al., in press; Mueser et al., 1998) Most have multiple experiences of trauma (Ibid) 34-53% report childhood sexual or physical abuse (Kessler et al., 1995; MHA NY & NYOMH, 1995) 43-81% report some type of victimization (Ibid) In terms of our public mental health system, one study done by Mueser identified that 90% of clients in the public mental health system had been exposed to trauma and that most of these people had had multiple episodes of trauma. 34% - 53% reporting childhood sexual or physical abuse and 43% - 81% reporting some type of victimization.In terms of our public mental health system, one study done by Mueser identified that 90% of clients in the public mental health system had been exposed to trauma and that most of these people had had multiple episodes of trauma. 34% - 53% reporting childhood sexual or physical abuse and 43% - 81% reporting some type of victimization.

42. Reported Prevalence of TraumaMental Health Population 97 % of homeless women with SMI have experienced severe physical and sexual abuse - 87% experience this abuse both as child and adult (Goodman et al., 1997) Current rates of PTSD in people with SMI range from 29-43% (CMHS/HRANE, 1995; Jennings & Ralph, 1997) Epidemic among population in public mental health system (Ibid) Female consumers who are without housing, are at particularly high risk. Ninety-seven percent of homeless women with serious mental illness have experienced severe physical and sexual abuse. 87% experienced this abuse in their childhood as well as adulthood. These women continue to be at tremendous risk. When we add substance abuse to the condition there are increased risks. These risks may involve relationships with people who are abusing drugs such as crack cocaine and PCP, disinhibiting drugs that may evoke aggression. Also women may use to numb out or self medicate. Life on the street or in shelter is often unsafe. We must be very cognizant about these risk factors and help them identify realistic safety plans. Female consumers who are without housing, are at particularly high risk. Ninety-seven percent of homeless women with serious mental illness have experienced severe physical and sexual abuse. 87% experienced this abuse in their childhood as well as adulthood. These women continue to be at tremendous risk. When we add substance abuse to the condition there are increased risks. These risks may involve relationships with people who are abusing drugs such as crack cocaine and PCP, disinhibiting drugs that may evoke aggression. Also women may use to numb out or self medicate. Life on the street or in shelter is often unsafe. We must be very cognizant about these risk factors and help them identify realistic safety plans.

43. Reported Prevalence of Trauma A majority of adult and children in inpatient psychiatric treatment settings have trauma histories (Cusack et al.; Mueser et al., 1998; Lipschitz et. Al, 1999, NASMHPD, 1998) �Many providers may assume that abuse experiences are additional problems for the person, rather than the central problem�� (Hodas, 2004) Recognizing trauma as a primary factor in the lives of those we serve is a key component to recovery. Without addressing the root cause of so many behaviors and conditions the process of healing cannot begin. Controlling behaviors rather than recognizing the shattering of lives caused by trauma serves neither systems nor consumers well.Recognizing trauma as a primary factor in the lives of those we serve is a key component to recovery. Without addressing the root cause of so many behaviors and conditions the process of healing cannot begin. Controlling behaviors rather than recognizing the shattering of lives caused by trauma serves neither systems nor consumers well.

44. Examples of trauma interventions Telling people what you are going to do before you do it Recognizing a flashback and managing it with words instead of action Seeing trauma responses as adaptations rather than manipulations

45. Universal Precautions as aCore Trauma Informed Concept Presume that every person in a treatment setting has been exposed to abuse, violence, neglect or other traumatic experiences.

46. What is a Crisis Prevention Plan? A Crisis Prevention Plan is more than just a plan. Fundamentally it is an individualized plan developed in advance to prevent a crisis and avoid the use of secure observation or disciplinary confinement. Read slide�Read slide�

47. What is a Crisis Prevention Plan? It is also: A therapeutic process A task that is trauma sensitive A plan that is tailored to the needs of each individual A partnership of safety planning A collaboration between service users and staff to create a crisis strategy together A youth-owned plan written in easy to understand language Read slide� Read slide�

48. Why Are Safety Tools Used? Purpose: To help service users during the earliest stages of escalation before a crisis erupts To help service users identify coping strategies before they are needed To help staff plan ahead and know what to do with each person if a problem arises To help staff use interventions that reduce risk and trauma to individuals Read slide� Read slide�

49. Essential Components 1. Triggers 2. Early Warning Signs 3. Strategies Read slide� Read slide�

50. First, Identify Triggers Read slide� Read slide�

51. Experiencing Emotional Triggers "I hated it. You people need to do better. Time of getting held does not mean you go straight to the restraint bed. You know me better than that. I hate the restraint bed. It makes me think of my past. How some things happened to my mom. You people do not understand that talking about your past can be very hard to do. I am sorry if I hurt any staff but you all know me. I do not mean to hurt you." Gail Ward, age 17 (LeBel, J., Stromberg, N., (2004) Experiences of S/R. Unpublished Papers) Read slide�Read slide�

52. Triggers A trigger is something that sets off an action, process, or series of events (such as fear, panic, upset, agitation): bedtime room checks large men yelling people too close Read slide� Read slide�

53. More Triggers: What makes you feel scared or upset or angry and could cause you to go into crisis? Not being listened to Lack of privacy Feeling lonely Darkness Being teased or picked on Feeling pressured People yelling Room checks Arguments Being isolated Being touched Loud noises Not having control Being stared at Other (describe) ________________ Read slide� Only some of the bullets, not all Read slide� Only some of the bullets, not all

54. More Triggers: Particular time of day/night___________ Particular time of year_______________ Contact with family _________________ Other* __________________________ * Youth have unique histories with uniquely specific triggers - essential to ask & incorporate Read slide� Read slide�

55. Second, Identify Early Warning Signs Read slide� Read slide�

56. Early Warning Signs A signal of distress is a physical precursor and manifestation of upset or possible crisis. Some signals are not observable, but some are, such as: restlessness agitation pacing shortness of breath sensation of a tightness in the chest sweating Read slide� Read slide�

57. Early Warning SignsWhat might you or others notice or what you might feel just before losing control? Clenching teeth Wringing hands Bouncing legs Shaking Crying Giggling Heart Pounding Singing inappropriately Pacing Eating more Breathing hard Shortness of breath Clenching fists Loud voice Rocking Can�t sit still Swearing Restlessness Other ___________ Read slide� only some of the bullets Read slide� only some of the bullets

58. Third, Identify Strategies Read slide� Read slide�

59. Strategies Strategies are individual-specific calming mechanisms to manage and minimize stress, such as: time away from a stressful situation going for a walk talking to someone who will listen working out lying down listening to peaceful music Read slide� Read slide�

60. Strategies:What are some things that help you calm down when you start to get upset? Time alone Reading a book Pacing Coloring Hugging a stuffed animal Taking a hot shower Deep breathing Being left alone Talking to peers Therapeutic Touch, describe ______ Exercising Eating Writing in a journal Taking a cold shower Listening to music Talking with staff Molding clay Calling friends or family (who?) ______ Read slide� only some of the bullets Read slide� only some of the bullets

61. More Strategies Blanket wraps Lying down Using cold face cloth Deep breathing exercises Getting a hug Running cold water on hands Ripping paper Using ice Having your hand held Going for a walk Snapping bubble wrap Bouncing ball in quiet room Using the gym Read slide� read only some of the bullets Read slide� read only some of the bullets

62. Even More Strategies Male staff support Female staff support Humor Screaming into a pillow Punching a pillow Crying Spiritual Practices: prayer, meditation, religious reflection Touching preferences Speaking with therapist Being read a story Using Sensory Room Using Comfort Room Identified interventions:_____ Read slide� Only some bullets Read slide� Only some bullets

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66. Individual Crisis Plan Additional Guidelines for use Help people �practice� strategies before they become upset Conduct training with staff and customers regarding guidelines for development and use Make sure a safety tool is filled out and placed in the record to help insure individual preferences about what is helpful and what is not in times of stress

67. How does work environment effect staff Hypervigilance Hyperarousal Irritability Anxiety If you find yourself experiencing any of these symptoms, talk with someone about it or write it down to clear your mind. Develop your own crisis prevention plan.

68. Male Direct Care Staff �When you get to that point you feel as though you have failed. It seems like you�ve missed something when you could have prevented it beforehand. I never liked doing that, but it�s about maintaining safety and you just never want that to happen�.you feel like you�ve failed. There�s always something you could have seen earlier if you had been there a little sooner, if you had known the client a little better. You could have prevented the situation.� (Jorgenson et al., 2006) Read slide�Read slide�

69. Female Staff Member �I am afraid I�ve lost my ability to really care. I�ve had to protect my heart so many times from the pain, that I don�t know how to take the armor off. I used to think of myself as a caring and compassionate person. That�s what I liked about myself. Now I am not sure. I think I have become callous or cold. I don�t think I like myself much anymore� (Saakvitne, Gamble, Pearlman & Lev, 2000.Risking Connection� (Sidran Press))

70. Male Direct Care Staff �I�ve been injured from time to time. Nothing severe. Yeah, sometimes I get headaches. I get shaky.�

71. �She asked if I would be safe if she took off the restraints, and I said yes. She said, �Well that is a good safe.�� When she took the restraints off of my wrists and legs I was unable to move my right hand and shoulder. It was very swollen. She couldn�t believe how swollen I was and immediately called for medical attention. It was her passion and conviction about the fact that I had not received any medical attention. She was screaming to whoever it was. Then she got me up and helped me take a shower and got me food. In her face I could see that she cared for me and also in her voice.� Sharon Gregory Value of Compassion There are also moments of profound compassion from those serving�Read slide�There are also moments of profound compassion from those serving�Read slide�

72. Experiences of Trauma in Care Settings �If I could say anything to all the staff in the world it would be this: forget everything you were taught in school and be prepared to listen�don�t criticize and think it�s a lie. Just listen and ask questions and be kind. Just take the time to listen�� (Interview with a adult trauma survivor (CD), 2005) Read slide�Read slide�

73. National Association of State Mental Health Program DirectorsNational Technical Assistance Center703-739-9333