Assessing for and Addressing Trauma in Recovery-Oriented Practice

Assessing for and Addressing Trauma in Recovery-Oriented Practice
Paula G. Panzer, M.D. Eric Arauz, MLER Kevin Ann Huckshorn RN, MSN, CADC Assessing for and Addressing Trauma in Recovery-Oriented Practice Implementing Recovery-Oriented Practices

January 25, 2012 Kevin Ann Huckshorn, RN, MSN, CADC Delaware Director for the Division of Substance Abuse and Mental Health Paula Panzer, M.D. Director of Training and Professional Development Jewish Board of Family and Children's Services Eric Arauz, MLER Arauz Inspirational Enterprises Adjunct Instructor, Department of Psychiatry, Robert Wood Johnson Medical School New Jersey Governor’s Council on Alcoholism and Drug Abuse APNA RTP Steering and Curriculum Committees Moderated by Larry Davidson, Ph.D. Project Director, Recovery to Practice (RTP) Development Services Group (DSG), Inc.

If you are not hearing the audio… To access the audio portion of this Webinar, please dial the conference service directly and enter the participant access code: Audio Conferencing (toll-free): Participant Access Code:

3–3:05 p.m. 3:05–3:10 p.m. 3:10–3:25 p.m. 3:25–3:40 p.m. 3:40–3:55 p.m. 3:55–4:30 p.m. Welcome Introductions & Overview Trauma-Informed Care: A Shift in Thinking for Service Providers Understanding and Addressing the Impact of Trauma in a Recovery-Oriented Practice The Trauma of Delusions Discussion Wilma Townsend SAMHSA/CMHS Larry Davidson, Ph.D. DSG, Inc. Kevin Ann Huckshorn RN, MSN, CADC Paula Panzer, M.D. Eric Arauz, MLER Participants & Presenters

Process for Questions, Answers, and Downloading Slides Our speakers will present their slides, which will be followed by moderated questions and answers. We encourage you to ask questions or make comments! To ask a question, click on the Q/A tab and type your question in the window that opens, or press *1 for the operator, who will take your question in the order in which it is received. This Webinar will be recorded and archived for future use. Please visit for more information.

Trauma-Informed Care: A Shift in Thinking for Service Providers
Kevin Ann Huckshorn Trauma-Informed Care: A Shift in Thinking for Service Providers Kevin Ann Huckshorn, RN, MSN, CADC DSAMH State Division Director Substance Abuse and Mental Health

Outline What is trauma? What is Trauma-Informed Care (TIC)?
What are the differences between a trauma-informed and uninformed service system? Trauma assessment

What Makes an Event Traumatic?
Traumatic Events Are Sudden, unexpected, and extreme. Usually involve physical harm or perceived life threat. (Research has shown perception of “life threats” is a powerful predictor 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, teenage years, and early 20s. All presuppose a greater impact on life in adulthood. (Tedeschi, 2011)

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 point 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)

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

How Many People Have Experienced Trauma?
What about the people we serve? What about people in other care settings? What is some of the research regarding the prevalence of trauma?

Prevalence of Trauma Mental Health Population: Adults
97% of homeless women with serious mental illness (SMI) experienced severe physical and sexual abuse 87% experienced abuse in both childhood and adulthood (Goodman et al., 1997) 90% of public mental health clients have been exposed to trauma had multiple experiences of trauma (Mueser et al., in press; Mueser et al., 1998) 81% of adults diagnosed with bipolar disorder or Dissociative Identity Disorder (90%) were sexually or physically abused as children (Herman et al., 1989; Ross et al., 1990) 29–43% of people with SMI have posttraumatic stress disorder (PTSD) (CMHS/HRANE, 1995; Jennings & Ralph, 1997) Image: Photo of homeless woman 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 rape

Prevalence of Trauma Mental Health Population: Children & Adolescents
Canadian study of 187 adolescents reported 42% had PTSD. (Kotlek, Wilkes, & Atkinson, 1998) In a U.S. study of 100 adolescent inpatients, 93% had histories of trauma 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 histories of trauma. (Massachusetts DMH, 2007) Image: Photo of young girl 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 –

Prevalence of Trauma: Substance Abuse Population
Up to 2/3 of men and women in SA treatment report childhood abuse and neglect. (CSAT, SAMHSA, 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 Mass., 2006) Image: Photo of drug-injecting man 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

Prevalence of Trauma: Incarcerated Women
Framingham Women’s Prison, Mass. 90% receiving mental health services or SA services have trauma histories. (Governor’s Task Force, Comm. of Mass., 2005) Correctional Institute for Women, R.I. 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) 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 – Image: Photo of imprisoned women

Prevalence of Trauma: Incarcerated Youth
93% of males in a juvenile justice (JJ) facility reported trauma history (compared to 84% females), but more females met criteria for PTSD (18% female, 11% male). (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: 3–50% in JJ settings and up to eight 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) Image: Photo of imprisoned man 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 –

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 health care settings. These individuals often experience depression, SA, serious mental conditions, vulnerability to re-victimization, difficulty working, and/or impaired social networks. (Hopper, Bassuk, & Olivet, 2010)

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 and author Image: Photo of Suzanne Somers

Well Known and Not-So-Well-Known People Aren’t Immune from Trauma
Desperate 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-so-well-known people have experienced trauma. Image: Celebrity photos

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 DOC or JJ systems 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. 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. (Hodas, 2004; Frueh et al., 2005; Mueser et al., 1998; Lipschitz et al., 1999; NASMHPD, 1998)

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 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 such as heart disease, pulmonary disease, liver disease, STDs, GYN cancer, and early death. 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 trauma (Felitti, Anda et al., 1998)

OK. So People Who Get Services in Public Health Care 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 multistep, staggered process that highlights three key focus areas: 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)

Implementing TIC: Outcomes
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. Trauma-informed services may have an improved and positive effect on housing stability (early research). Trauma-informed services may lead to a decrease in crisis services use 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)

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

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)

Universal Precautions
These kinds of “precautions” are aimed at preventing illness or injury before it happens. Like hand-washing techniques to avoid transmitting germs or using condoms for “safe sex.” In a trauma-informed setting, this means using strategies to ensure comfort: always be welcoming, avoid conflict/violence, meet needs assertively, and minimize any traumatic event that could hurt clients or staff. (NETI, 2010)

What Does All This Mean? For the people we serve, the outcomes of traumatic life experiences primarily mean 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)

The Three Contexts of Healing When Systems 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 an early developmental stage called “trust vs. mistrust.” To bridge this gap, TIC systems have to first build trust. (Bath, 2008)

Connections: The second pillar of TIC expects the healthy development of relationships between service recipients 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)

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

What Does a Trauma-Informed Care System Look Like?

Trauma Informed Non-Trauma Informed
How 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 and “universal” precautions Person seen without family/social history “Tradition of Toughness” valued as best care approach

How 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 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.

How 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 and volitional Labeling language: manipulative, needy, gamey, “attention seeking” Lack of Peer Supports Closed system—advocates discouraged 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 pain (Fallot & Harris, 2002; Cook et al., 2002; Ford, 2003; Frueh et al., 2005; Jennings, 1998; Prescott, 2000)

The Importance of Carefully Assessing Trauma

Why Is Trauma Assessed? A more sensitive review of someone’s trauma history should be conducted 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 information from referral sources or do a short assessment themselves. (Cook et al., 2002; Fallot & Harris, 2002; Maine BDS, 2000)

Common Trauma Symptoms People Struggle With
Dissociation Flashbacks Nightmares Hypervigilance Terror Anxiety Negative auditory hallucinations Numbness Depression Substance abuse Self-injury Eating problems Sexual promiscuity Poor judgment and continued cycle of victimization . 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. (DSM IV-TR, 2000)

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? A family member? (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. (Carmen et al., 1996)

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. Addresses context of the human experience rather than a pathology framework (Bloom, 2002)

Trauma Assessment: Key Principles
Information from the assessment and “positive responses” should 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 … 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 dolls

In Summary… Most 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?

“If you can, help others; if you cannot do that,
at least do not harm them.” —Dalai Lama

Contact Information Kevin Huckshorn, RN, MSN, CADC DSAMH Phone: NCTSN.org

Paula G. Panzer Understanding and Addressing the Impact of Trauma in a Recovery-Oriented Practice: Key Concepts Paula G. Panzer, M.D. Director of Training and Professional Development Jewish Board of Family and Children's Services New York, N.Y.

Understanding trauma is not just about acquiring knowledge.
It’s about changing the way you view the world. —Sandra Bloom, 2007

Because coping responses to abuse and neglect are varied and complex, trauma survivors may carry any psychiatric diagnosis and frequently trauma survivors carry many diagnoses. Sidran Institute, 2010

We Create Shared Definitions …
… to create a common understanding and language We start with those involved in the dialogue Consumers Clinicians Community partners We define to develop policies and practices We check in to make sure the definition is relevant

Shared Definitions Trauma Traumatic Stress Traumatic Stress Disorders
Trauma-Informed Care Trauma-Specific Services

Trauma Traumatization
Trauma—something that threatens one’s psychic or physical integrity Traumatization occurs when both internal and external resources are inadequate to cope with external threat. (Bessel van der Kolk, 1989)

Traumatic Stress and Traumatic Stress Disorders
Physical and emotional responses of an individual to trauma When traumatic events overwhelm an individual’s ability to cope and elicit feelings of terror, powerlessness, rage, and out-of- control physiological arousal Disorders related to and/or specifically a result of trauma exposure PTSD ASD DID …DES NOS And then some less clearly defined Protect – Promote Safety and Trustworthiness Connect – Focus on Relationships Respect – Engage in Choice and Collaboration Redirect (Teach and Reinforce) – Encourage Skill-Building and Competence (Adapted from Hummer, V., Crosland, K., and Dollard, N., 2009)

Trauma-Specific Services (TSS)
Trauma-Specific Services (TSS) are models designed to treat the psychological and behavioral consequences of trauma exposure. Targeted to the period of time relative to trauma exposure (immediate, short-term, and delayed) and to the type of reactions and symptoms being addressed (e.g., supporting adaptive coping after a disaster or treating chronic PTSD). Based upon evidence for effective interventions. TSS should be delivered in a TIC system. TSS are recovery oriented ONLY when offered in a person-centered and empowering manner.

Trauma-Informed Lens and Assessment
Trauma-informed work requires use of an informed lens. Trauma histories and trauma symptoms are not usually spontaneously offered. We must ask. Image: Sunglasses

Traumatic Stress Responses and Symptoms
Activation responses Trigger response Level of activation Avoidance responses Emotional numbing, dissociation, denial, thought suppression Intrusive and incomplete remembrance Avoidance of trauma reminders Re-experiencing Hyperarousal Trauma-related, sexualized, aggressive, or oppositional behaviors Dissociation Unsafe behaviors

AVOIDANCE Many consumers won’t initiate discussion about trauma exposure because they may fear talking about the trauma will trigger them and cause an intense and painful reaction may feel embarrassed, guilty, responsible for, or stigmatized by experiences trauma memories are typically fragmented and confusing some have been rejected or further injured with prior attempts to tell past experiences with telling have been too painful abusers threatened retaliation if the secret was revealed Many clinicians are reluctant to initiate discussion about trauma exposure studies show clinicians underestimate the incidence of consumer trauma exposure and fail to ask fear it will be too distressing for their consumers fear the effect it will have on them, or feel they don’t have the skills to help the consumer after disclosure undervalue the story of the trauma and overvalue their assumptions on the consumer

Subjective Unit of Distress Scale (SUDS)
Therapeutic Window 4-7 Image: “The Feeling Thermometer” chart

PTSD Protective Factors
PTSD is a failure of natural recovery with both risk factors and protective factors. Social support is a key mediating factor Believing and validating the experience Feeling good about one’s own actions in the face of danger Cognitive and self-regulation abilities Positive belief about oneself Motivation to act effectively in environment

Factors to Consider for Treatment Planning
How trauma history is impacting current behavior How triggers/reminders are impacting behavior Establish purpose for a trauma-specific intervention Be mindful of ongoing trauma and environmental risks Consumer to establish goals That address symptoms and function That take into consideration the power of avoidance That respect meaning making and coping That start from a strengths perspective Clear roles for consumer and clinician over the course of the intervention and the value of community supports Image: Unlatched chest

Risks of Not Treating Trauma-Related Disorders
Consumer not heard, valued, understood Most trauma-specific disorders are treatable The trauma-specific distress can disrupt functioning and exacerbate co-occurring disorders Missed opportunity for human connections Missed chance for meaning making

Trauma-Specific Services

Trauma-Specific Services in a Recovery-Oriented Practice
Intervention choices in response to experiencing symptoms To prevent or minimize symptoms To manage or overcome the disorder

Get to Know the Treatments
Evidence-based/supported trauma tx CBT TF–CBT; CTG–CBT CPT CPP TST STAIR EMDR SPARCS TREM Seeking Safety PE (Prolonged Exposure) Medication Others? Non-trauma-specific EBTs and non- EB treatments often used with traumatized consumers DBT MST FFT STEPPS PCIT Somatic treatments (sensorimotor, somatic experiencing, yoga, etc.) Psychodrama therapy Narrative Therapy IPT Others?

Commonalities of Phased Trauma Treatments
Safety and stabilization—preparatory phase; purpose is to restore and/or strengthen consumer’s sense of safety and coping skills, and can include the following. Elements of phase will be repeated and reinforced throughout the next two phases. Skills for affect and interpersonal regulation Learning and practice of coping, relaxation, and grounding techniques Psychoeducation Cognitive coping techniques, thought stopping, and attention shifting Provides opportunity for consumer and clinician to build a therapeutic alliance Makes use of spirituality and safe connections

Phase One: Safety and Stabilization (cont’d)
Managing Emotions Affective education and regulation Grounding techniques Breathing retraining Progressive muscle relaxation Imagery Self-talk Containment and distraction

Phase One: Safety and Stabilization (cont’d)
Feeling Identification Identification of affect and intensity Labeling feelings Identification of connection between feeling, thoughts, and behaviors Identification of how consumers experience distress, such as Body: where the distress is located in their bodies. (Those who dissociate don’t necessarily experience distress this way.) Sense of body in space. Racing thoughts Grounding Necessary first step for affect regulation and active coping Early, temporary way to manage and contain overwhelming feelings by focusing on a specific sensory pathway for containment

2. Remembrance and mourning—provides some form of exposure therapy whereby traumatic events are recalled and cohesively assembled. This phase helps end cycle of PTSD (and is done when it is POST trauma). Exposure can include the following Creation of trauma narrative Processing and integration of traumatic experiences Desensitization through repeated telling of trauma story and/or exposure to fears or aspects avoided Addressing 1 & 2 distorted cognitions

3. Reconnection—emotions and cognitions revealed during the exposure phase are examined; treatment moves beyond trauma experience and is connected to consumer’s interpersonal life Identification and modulation of cognitive distortions Meaning making Processing and integration of trauma experience Preparation for returning to daily life Coping with real losses as a result of the trauma(s)

Shared Characteristics of EB and Promising Practices
Function as service components within systems of care Are provided in the community Utilize natural supports and partner with families, with training and supervision provided by those with formal training Operate under the auspices of all systems serving children, adults, and families Integrated with other treatment interventions Recovery-oriented focus

Secondary Traumatic Stress (Overview)

Secondary Traumatic Stress
Secondary Traumatic Stress is a natural, normal, potential effect of empathic engagement with a traumatized person. Doing our job puts us at risk for secondary trauma.

Different Levels of Effects
First order Effects—Lower level Belief systems Personal control and invulnerability Personal competence Live in a just and benevolent world Goodness of others Higher level—Effects mimic typical PTSD symptoms Re-experiencing Numbing/arousal Hyperarousal

Risk Factors Degree of Exposure—(thought to be the primary risk factor) qualitative and quantitative/cumulative Intensity of work demand/stress overload Personal history of trauma Lack of social support/isolation Punitive work environment Lack of appropriate and supportive supervision Exposure to acts of terrorism and violence outside of work

Protective Factors: Systemic, Professional, Personal
Self-awareness Self-nurturance Escape (not trauma avoidance!) Humor Active Coping Connection—Support Meaning Making Transformation

Enact Balance Outlays of Energy … Balanced by … Replenishment of Energy Image: Balance scale (Mary Jo Barrett, 2009)

Personal Self-Care Within the Workplace
Pacing—time management skills Build in time to talk to colleagues and have a collegial support system in place Build a personal sense of safety and de-stress: take breaks—even for a few minutes at a time, eat lunch, walk, breathe, don’t answer every call immediately, flowers in office, music you like Utilize supervision and crisis help Managing and tolerating the strong effects raised in the course of this work Review your caseload—how many consumers have trauma histories? Can changes be made moving forward?

Personal Self-Care Outside the Workplace
Consider therapy for unresolved trauma, which the therapeutic work may be activating Practice stress management through meditation, prayer, conscious relaxation, deep breathing, and exercise Keep in contact with trusted others Engage in hobbies and enjoyed activities Get quiet time Develop a written plan focused on maintaining work–life balance

Contact Information Paula G. Panzer, M.D. Jewish Board of Family and Children’s Services New York, N.Y. Center for Trauma Program Innovation Martha K. Selig Educational Institute

The Trauma of Delusions
Eric Arauz, MLER The Trauma of Delusions Eric Arauz, MLER Arauz Inspirational Enterprises

The Trauma of Delusions
Image: Pablo Picasso’s “Guernica”

…this led to a lifelong phobia of sharks.
While in a manic episode, a man had a recurring delusion of a shark attack… Image: Man being attacked by shark …this led to a lifelong phobia of sharks.

The Blasphemy of Mania Image: “Man of Fire,” Jorge Orozco

Religious Feeling Emulates Sickness
Mental illness has stolen God from me …

Recovery “The patient must find the courage to direct his attention to the phenomena of his illness. His illness must no longer seem to him contemptible, but must become enemy worthy of his mettle, a piece of his personality, which has solid ground for its existence, and out of which things value for his future life have to be derived.” —Sigmund Freud (from Trauma and Healing, Dr. Judith Herman)

“Art, not psychology, is the language of emotions.”
Image: “The Madhouse,” Francisco de Goya Critique of Religion and Philosophy (1958), Walter Kaufmann

Language of Madness Language of the heart: addiction
Alternative to clinical language Feel versus logic Subjective versus objective

Resources for Practitioners
Frankenstein (1818), Mary Shelley: Created by doctors; conscious of his otherness to society; stigmatized as monster Diary of a Madman (1835), Nikolai Gogol: Narrative of delusions; elucidates the progression of madness Hamlet (1603), William Shakespeare: Duality of mind; aware that thought may not be sound The Metamorphosis (1915), Franz Kafka: Experience of turning into something your family fears and does not understand; what it can feel like after hospital “Freak on a Leash” (1998), Korn: “Something takes a part of me, Something lost and never seen, Every time I start to believe, Something’s raped and taken from me, from me”; hyperarousal of biological disease

Eric Arauz, MLER President, Arauz Inspirational Enterprises LLC
Adjunct Instructor, Psychiatry: Robert Wood Johnson Medical School Special State Officer, N.J. Governor’s Council on Alcoholism and Drug Abuse New York Times Contributor International Trauma Trainer 2009 SAMHSA/U.S. Department of Health and Human Services “Voice Award” recipient for National Advocacy Lecturer at SAMHSA, NASMHPD, Yale University, Purdue University, Bristol–Myers Squibb, etc. Featured on ABC’s Good Morning America “Now–Mind and Mood” special Keynote 2010 American Psychiatric Nurses Convention in Louisville, K.Y.; numerous national keynotes Disabled American veteran who served in U.S. Navy in Operation Desert Shield

Contact Information Eric Arauz, MLER

Q&A, Discussion, and Summary
To ask a question, click on the Q/A tab and type your question in the window that opens, or press *1 for the operator, who will take your question in the order in which it is received. Larry Davidson, Ph.D. Project Director, Recovery to Practice DSG, Inc. Thanks for joining our Webinar today! Image: Photo of Larry Davidson, Ph.D.

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