1. OVERDOSE SOLUTIONS 2013 THE ROLE OF TRAUMA INFORMED CARE IN DECREASING RELAPSE AND OVERDOSE POTENTIAL Amy Buehrer, LSW Vice President of Clinical Services and Chief Compliance Officer, Pyramid Healthcare, Inc.

2.  Individuals with a mental health disorder or a substance dependency are stereotyped by the general population  Individuals with co occurring disorders are even more vulnerable

3. Over 100 people die from drug overdose every day in the United States (CDC) In 2005, relapse rates after some form of treatment rated from 50%-90% 75% of women and men in substance abuse treatment report abuse and trauma histories (SAMHSA/CSAT, 2000).

4.  DSM-IV defines a “traumatic event” as one in which a person experiences, witnesses, or is confronted with actual or threatened death or serious injury, or threat to the physical integrity of oneself or others. ◦ Includes what is real and what is perceived ◦ Include a sense of helplessness + fear, horror or disgust ◦ Is greatly grounded in personal perception

5.  Emotional/Developmental age or “stuckness”  Defense mechanisms/inappropriate behaviors

6.  Disruptive behaviors  Poor frustration tolerance  Depression/withdrawal  Apathy/loss of interest in goals  Anxiety/worry  Poor concentration or focus  Fighting  Truancy  Substance abuse/dependency

7.  Abandonment  Self-Esteem/Self-Concept  Identity  Trust  Self-Sabotage  Self-Abusive/Self-Harm  Isolation/Withdrawal  Sexually Promiscuous or Withdrawn  Relationship Problems  Food/Body/Weight Issues  Excessive Spending  Power/Control Issues

8.  Every time something painful happens, we push it behind “The Wall” ◦ “Sore spot” (nerve endings, buttons)  Sore spot will be triggered when in current situation similar to 1st event  Memory keeps its power indefinitely – until digested/processed  The memories are not content to stay there (start to leak out)  Influences emotional feelings, physical feelings, negative core beliefs

9.  I am unsafe  I am unlovable  I am no good  I can’t trust people  The world is bad  I am a terrible person  It is all my fault

10.  Purpose: ◦ Create SAFE environment ◦ Teach discipline & external structure until internalized  Program Structure ◦ Schedule ◦ Rules ◦ Expectations re: Behavior & Interactions ◦ Accountability  Sanctions/Consequences

11.  Is 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.  Recognizes that most inappropriate behaviors are the learned behavior of past experiences http://mentalhealth.samhsa.gov/nctic/trauma.asp

12. ◦ Most who present for MH/CD treatment have experienced one or more traumas ◦ Trauma-sensitive treatment significantly increases an individual’s engagement and success in treatment ◦ Shift in viewpoint that SA, MH issues and Trauma are intertwined and that abuse of chemicals and MH symptoms are manifestations of untreated trauma. ◦ Source: http://www.wafca.org/trauma_sensitive_care.htmhttp://www.wafca.org/trauma_sensitive_care.htm

13.  Developed by Ricky Greenwald ◦ EMDR Within a Phase Model of Trauma-Informed Treatment, The Haworth Press, 2007

14.  Assumption that all clients have history of trauma  Every incident/behavior is viewed as opportunity for learning/processing vs. negativity/resistance  Staff asks: “What happened?” “What is going on?”  Expectations and interventions ◦ Are stage-specific and individualized ◦ Treatment progress is often erratic ◦ Balance Empathy and Accountability  “Compassionate Skepticism”  Staff maintains “groundedness” & stability in face of chaos & conflict – avoids personalization & reactivity

15.  Respect the client as an individual  Recognize his/her rights, needs and opinions  Understand & accept his/her behavior as a learned response to trauma/loss/stress.  Works to help strengthen the client’s self concept and belief system  Addresses negative core beliefs and introduces positive  Acknowledges small accomplishments

16.  Safety ◦ Introduce rules/expectations ◦ Conditions of confidentiality  Structure ◦ In the parameters of identifying trauma  Sensitivity ◦ Continual monitoring of how client doing  Success ◦ Help Ct build track record of success through achievement of small goals

17.  The Grocery List  Float Back, Meditation  Resource Installation  Positive Core Beliefs  Perceived Threat/Relaxation  Skill Development

18. PROGRAM/STAFF Level  Understanding of Trauma & Trauma-Sensitive Care  Decreasing Unrealistic expectations re: outcomes  Consistency in enforcement of program structure & rules  Eliminating Black & White/Either-Or thinking & decision-making ◦ “The LINE”  Staff self-awareness re: own issues ◦ Act out & pass on to clients Trauma-Informed Programming