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Trauma Informed System of Care: Changing Our Perspective Raul Almazar, RN, MA Senior Consultant National Center for Trauma Informed Care Almazar Consulting.

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Presentation on theme: "Trauma Informed System of Care: Changing Our Perspective Raul Almazar, RN, MA Senior Consultant National Center for Trauma Informed Care Almazar Consulting."— Presentation transcript:


2 Trauma Informed System of Care: Changing Our Perspective Raul Almazar, RN, MA Senior Consultant National Center for Trauma Informed Care Almazar Consulting

3 What is Trauma? Definition (NASMHPD, 2006) – The experience of violence and victimization including sexual abuse, physical abuse, severe neglect, loss, domestic violence and/or the witnessing of violence, terrorism or disasters DSM IV-TR (APA, 2000) – Person’s response involves intense fear, horror and helplessness – Extreme stress that overwhelms the person’s capacity to cope Almazar Consulting

4 Events Events/circumstances cause trauma. Experience An individual’s experience of the event determines whether it is traumatic. Effects Effects of trauma include adverse physical, social, emotional, or spiritual consequences. The Three E’s in Trauma Slide 4

5 Traumatic Events: (1)render victims helpless by overwhelming force; (2)involve threats to life or bodily integrity, or close personal encounter with violence and death; (3) disrupt a sense of control, connection and meaning; (4) confront human beings with the extremities of helplessness and terror; and (5) evoke the responses of catastrophe. (Judy Herman, Trauma and Recovery, (1992) Almazar Consulting

6 Effect of Trauma The effect of trauma on an individual can be conceptualized as a normal response to an abnormal situation. Slide 6


8 Prevalence 80% of child fatalities due to abuse and neglect occur within the first 3 years of life and almost always in the hands of adults responsible for their care. In the US, we lose an average of more than 9 children and youths ages 5 to 18 to homicide or suicide per day. According to the National Survey of Children Exposed to Violence, an estimated 46 million of the 76 million (61%) of children currently residing in the US are exposed to violence, crime and abuse each year. 1 in 10 children in this country are polyvictims.

9 Effects Their fear, anxiety, grief, guilt, shame, and hopelessness are further compounded by isolation and a sense of betrayal when no one takes notice or offers protection, justice, support, or help. Exposure to violence in the first years of childhood deprives children of as much as 10% of their potential IQ, leaving them vulnerable to serious emotional, learning and behavior problems by the time reach school age.

10 National Child Abuse Statistics 2011 ( A report of child abuse is made every ten seconds. More than four children die every day as a result of child abuse. It is estimated that between 50-60% of child fatalities due to maltreatment are not recorded as such on death certificates. Approximately 80% of children that die from abuse are under the age of 4. More than 90% of juvenile sexual abuse victims know their perpetrator in some way. Almazar Consulting

11 National Child Abuse stats cont. Child abuse occurs at every socioeconomic level, across ethnic and cultural lines, within all religions and at all levels of education. About 30% of abused and neglected children will later abuse their own children, continuing the horrible cycle of abuse. In at least one study, about 80% of 21 year olds that were abused as children met criteria for at least one psychological disorder. The estimated annual cost of child abuse and neglect in the United States for 2008 is $124 billion. Almazar Consulting

12 National Child Abuse stats cont. Children who experience child abuse & neglect are about 9 times more likely to become involved in criminal activity. Abused children are 25% more likely to experience teen pregnancy. Abused teens are more likely to engage in sexual risk taking, putting them at greater risk for STDs. As many as two-thirds of the people in treatment for drug abuse reported being abused or neglected as children. More than a third of adolescents with a report of abuse or neglect will have a substance use disorder before their 18th birthday, three times as likely as those without a report of abuse or neglect. Almazar Consulting


14 What does the prevalence data mean? The majority of adults and children in mental health treatment settings have trauma histories as do children and adults served in a variety of other behavioral and justice settings There appears to be a strong relationship between victimization and later offending (Hodas, 2004; Frueh et al, 2005; Mueser et al, 1998; Lipschitz et al, 1999; NASMHPD, 1998) Almazar Consulting

15 Therefore... We need to presume the clients we serve have a history of traumatic stress and exercise “universal precautions” (Hodas, 2004) Almazar Consulting

16 Prevalence in the General Population  90% of public mental health clients have been exposed to trauma.  In the general population, 61% of men and 51% of women reported exposure to at least one lifetime traumatic event, but majority reporting more than one traumatic event. (Kessler, et al, 1995) Almazar Consulting


18 Trauma Sensitive Person Served Trauma Assessment And Treatment Almazar Consulting

19 Trauma Sensitive Person Served Trauma Assessment And Treatment Universal Precautions Trauma Informed Care Almazar Consulting

20 Person Served Trauma Sensitive Trauma Assessment and TX Trauma Informed System Non- Coercive Non- Controlling Partnerships Collaboration Resiliency Recovery Hope Healing Almazar Consulting

21 ACE Study Compares adverse childhood experiences against adult status, on average, a half century later Almazar Consulting

22 ACE Study slides are from: – Robert F. Anda MD at the Center for Disease Control and Prevention (CDC) – September 2003 Presentation by Vincent Felitti MD “Snowbird Conference” of the Child Trauma Treatment Network of the Intermountain West – “The Relationship of Adverse Childhood Experiences to Adult Medical Disease, Psychiatric Disorders, and Sexual Behavior: Implications for Healthcare” Book Chapter for “The Hidden Epidemic: The Impact of Early Life Trauma on Health and Disease” Lanius & Vermetten, Ed) Almazar Consulting

23 Other Critical Trauma Correlates: The Relationship of Childhood Trauma to Adult Health Adverse Childhood Events (ACEs) have serious health consequences Adoption of health risk behaviors as coping mechanisms – eating disorders, smoking, substance abuse, self harm, sexual promiscuity Severe medical conditions: heart disease, pulmonary disease, liver disease, STDs, GYN cancer Early Death (Felitti et al., 1998) Almazar Consulting

24 Adverse Childhood Experiences – Recurrent and severe physical abuse – Recurrent and severe emotional abuse – Sexual abuse Growing up in household with: – Alcohol or drug user – Member being imprisoned – Mentally ill, chronically depressed, or institutionalized member – Separation/Divorce – Mother being treated violently – Both biological parents absent – Emotional or physical abuse (Fellitti,1998) Almazar Consulting

25 ACE Questions: While you were growing up, during your first 18 years of life: 1. Did a parent or other adult in the household often or very often… Swear at you, insult you, put you down, or humiliate you? Or Act in a way that made you afraid that you might be physically hurt? 2. Did a parent or other adult in the household often or very often… Push, grab, slap, or throw something at you? Or Ever hit you so hard that you had marks or were injured? 3. Did an adult or person at least 5 years older than you ever… Touch or fondle you or have you touch their body in a sexual way? Or Attempt or actually have oral, anal, or vaginal intercourse with you? 4. Did you often or very often feel that … No one in your family loved you or thought you were important or special? Or Your family didn’t look out for each other, feel close to each other, or support each other? Almazar Consulting

26 ACE Questions: Con’t 5. Did you often or very often feel that … You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? Or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it? 6. Were your parents ever separated or divorced? 7. Was your mother or stepmother: Often or very often pushed, grabbed, slapped, or had something thrown at her? Or Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? Or Ever repeatedly hit at least a few minutes or threatened with a gun or knife? 8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs? 9. Was a household member depressed or mentally ill, or did a household member attempt suicide? 10. Did a household member go to prison? Almazar Consulting

27 Severe and persistent emotional problems Health risk behaviors Serious social problems Adult disease and disability High health and mental health care costs Poor life expectancy For example: The following information and slides are from September 2003 Presentation at “Snowbird Conference” of the Child Trauma Treatment Network of the Intermountain West, by Vincent J. Felitti, MD. And from Lanius/Vermetten Book Chapter 6/2007 The higher the ACE Score, the greater the likelihood of :

28 Adverse Childhood Experiences are Common Of the 17,000 HMO Members: 1 in 4 exposed to 2 categories of ACEs 1 in 16 was exposed to 4 categories. 22% were sexually abused as children. 66% of the women experienced abuse, violence or family strife in childhood. Almazar Consulting

29 The ACE Comprehensive Chart 29 Adverse Childhood Experiences Neurobiological Impacts and Health Risks Long-term Health and Social Problems The more types of adverse childhood experiences… The greater the neurobiological impacts and health risks, and… The more serious the lifelong consequences to health and well- being

30 Emotional Problems Almazar Consulting

31 Childhood Experiences Underlie Chronic Depression Almazar Consulting

32 Childhood Experiences Underlie Suicide Almazar Consulting

33 2/3 rd (67%) of all suicide attempts 64% of adult suicide attempts 80% of child/adolescent suicide attempts Are Attributable to Childhood Adverse Experiences Women are 3 times as likely as men to attempt suicide Men are 4 times as likely as women to complete suicide.

34 ACE Score Ever Hallucinated* (%) *Adjusted for age, sex, race, and education. ACE Score and Hallucinations Almazar Consulting

35 ACE Score and Impaired Memory ACE Score and Impaired Memory of Childhood of Childhood Percent With Memory Impairment (%) ACE Score ACE Score ACE Score Almazar Consulting

36 Health Risk Behaviors Almazar Consulting

37 Adverse Childhood Experiences and Current Smoking % Almazar Consulting

38 Childhood Experiences and Adult Alcoholism Almazar Consulting

39 ACE Score and Intravenous Drug Use N = 8,022 p<0.001 Almazar Consulting

40 “Male child with an ACE score of 6 has a 4600% increase in likelihood of later becoming an IV drug user when compared to a male child with an ACE score of 0. Might drugs be used for the relief of profound anguish dating back to childhood experiences? Might it be the best coping device that an individual can find?” (Felitti, 1998) Almazar Consulting

41 Is drug abuse self- destructive or is it a desperate attempt at self-healing, albeit while accepting a significant future risk?” (Felitti, 1998) Almazar Consulting

42 Basic cause of addiction is experience-dependent, not substance-dependent Significant implications for medical practice and treatment programs Almazar Consulting

43 Serious Social Problems Almazar Consulting

44 Childhood Experiences Underlie Rape Almazar Consulting

45 Women with ACE Score of 4+ are 500% more likely to become victims of domestic violence. Both men and women are more likely to become perpetrators of domestic violence ACEs Underlie Domestic Violence

46 Almazar Consulting


48 Adverse Childhood Experiences and Likelihood of > 50 Sexual Partners Almazar Consulting

49 ACE Score and Unintended Pregnancy or Elective Abortion Almazar Consulting

50 Adverse Childhood Experiences and History of STD Almazar Consulting

51 Sexual Abuse of Male Children and Their Likelihood of Impregnating a Teenage Girl Not 16-18yrs yrs <=10 yrs abused Age when first abused Percent who impregnated a teenage girl 1.3x 1.4x 1.8x 1.0 ref Almazar Consulting

52 Frequency of Being Pushed, Grabbed, Slapped, Shoved or Had Something Thrown at Oneself or One’s Mother as a Girl and the Likelihood of Ever Having a Teen Pregnancy Never Once, Sometimes Often Very Twice often Percent who had a teen pregnancy Pink =self Green =mother Almazar Consulting

53 ACE Score and Indicators of Impaired Worker Performance Prevalence of Impaired Performance (%) Almazar Consulting

54 “What happened to you?” instead of “What’s wrong with you?” Almazar Consulting

55 From “What’s Wrong?” To, “What’s Happened?” What is your diagnosis? What are your symptoms? How can I best help or treat you? What is your story? How did you end up here? How have you coped and adapted? How can we work together to figure out what helps?

56 om Trauma Symptoms = Tension Reducing Behaviors “How do I understand this person?” rather than “How do I understand this problem or symptom?”

57  All behavior has meaning  Symptoms are ADAPTATIONS  Comfort vs. Control  We build on success not deficits Almazar Consulting

58 Resilience Questionnaire

59 What’s Your Resilience Score? This questionnaire was developed by the early childhood service providers, pediatricians, psychologists, and health advocates of Southern Kennebec Healthy Start, Augusta, Maine, in 2006, and updated in February Two psychologists in the group, Mark Rains and Kate McClinn, came up with the 14 statements with editing suggestions by the other members of the group. The scoring system was modeled after the ACE Study questions. The content of the questions was based on a number of research studies from the literature over the past 40 years including that of Emmy Werner and others. Its purpose is limited to parenting education. It was not developed for research.

60 Please circle the most accurate answer under each statement: 1. I believe that my mother loved me when I was little. 2. I believe that my father loved me when I was little. 3. When I was little, other people helped my mother and father take care of me and they seemed to love me. 4. I’ve heard that when I was an infant someone in my family enjoyed playing with me, and I enjoyed it, too. 5. When I was a child, there were relatives in my family who made me feel better if I was sad or worried.

61 6. When I was a child, neighbors or my friends’ parents seemed to like me. 7. When I was a child, teachers, coaches, youth leaders or ministers were there to help me. 8. Someone in my family cared about how I was doing in school. 9. My family, neighbors and friends talked often about making our lives better. 10. We had rules in our house and were expected to keep them.

62 11. When I felt really bad, I could almost always find someone I trusted to talk to. 12. As a youth, people noticed that I was capable and could get things done. 13. I was independent and a go-getter. 14. I believed that life is what you make it. How many of these 14 protective factors did I have as a child and youth? (How many of the 14 were circled “Definitely True” or “Probably True”?)

63 CAPABILITY Intellectual & employable skills Self regulation – self control, executive function, flexible thinking Ability to direct & control attention, emotion, behavior Positive self view, efficacy ATTACHMENT & BELONGING Bonds with parents and/or caregivers Positive relationships with competent and nurturing adults Friends or romantic partners who provide a sense of security & belonging COMMUNITY, CULTURE, SPIRITUALITY Faith, hope, sense of meaning Engagement with effective orgs – schools, work, pro-social groups Network of supports/services & opportunity to help others Cultures providing positive standards, expectations, rituals, relationships & supports KEY SYSTEMS FOR RESILIENCE Nourishment Protection Growth Wholeness

64 EXAMPLES OF PROGRAM & POLICY ACTIONS Safe Harbor Crisis Nursery in the Tri-Cities has incorporated ACEs and trauma into its day-to-day strategies and case management resulting in improved outcomes for families. Children of Incarcerated Parents; the Legislature has mandated the executive branch to engage in an initiative to address the needs of children of incarcerated parents. The initiative and its processes are framed to address the likelihood that these children have more than this one ACE. With the help of the Mental Health Transformation Grant and the Office of the Superintendent of Public Instruction (OSPI), Spokane is exploring the creation/implementation of trauma sensitive practices in public schools. OSPI introduced the Compassionate Schools initiative, which supports local school districts in reducing the non-academic barriers to schools success that are created by trauma (2008). ( Parent Trust for Washington Children has incorporated the ACE questions into their work with addicted parents facing court action (DV, termination of parental rights) resulting in: 1) improved outcomes in parenting classes and 2) reduced relapse among parents with 4 or more ACEs.

65 Punishment vs. Compassion Discipline by Enforcement of Punishment, Obedience Zero Tolerance and no skill building to manage stress Totalitarian atmosphere, Fear, vigilance and mistrust Regard unruly behavior as willful disobedience Students feel like potential criminals What’s wrong with this kid? Suspensions and absenteeism down 30% Discipline by Respect, Understanding, Compassion Fair Consequences and skill building to manage stress Atmosphere of Safety and Trusting Relationships Regard unruly behavior as a manifestation of trauma Students feel understood and treated fairly What is happening with this kid? Suspensions and absenteeism down 87% Killarney Secondary School 2010 – 2013 Vandalism, false fire alarms, locker break- ins drug deals common Lincoln High School 2009 – 2011 Kids kicked out of other schools, last chance; gangs controlled building.

66 Neurodevelopment of Childhood Bruce D. Perry, M.D., Ph.D.

67 How Trauma Affects the Brain Experiences Build Brain Architecture Experiences Build Brain Architecture Serve & Return Interaction Shapes Brain Circuitry Serve & Return Interaction Shapes Brain Circuitry Toxic Stress Derails Healthy Development Toxic Stress Derails Healthy Development Slide 67

68 The Brain Matters The human brain is the organ responsible for everything we do. It allows us to love, laugh, walk, talk, create or hate. The brain - one hundred billion nerve cells in a complex net of continuous activity -allows us our humanity. For each of us, our brain’s functioning is a reflection of our experiences.

69 The biological unit of survival for human beings is the clan. Evolutionary pressure which resulted in our species was applied to the clan, not the individual. We are unavoidably inter-dependent upon each other.

70 The compartmentalization of Western life Separate by age Separate by wealth Separate by work Separate in education, by profession Separate by transportation Separate by generation Separate by ethnicity, religion, race

71 Decrease in Size of Households Privacy and Isolation

72 Developmental Stages Emotional Regulation for infants Maternal dyad Repetitive, patterned interaction to hardwire self-regulation Exploration of individual self, tentative independence, tolerating manageable separations Independence

73 Brainstem Blood pressure Body temperature Heart rate Arousal states Diencephalon Motor regulation Affect regulation Hunger/satiety Sleep Limbic Affiliation Attachment Sexual Behavior Emotional Reactivity Neocortex Abstract Thought Concrete Thought Mother Caregiver Family and Friends Peers, Teachers Community

74 Rauch Brain scans

75 (Restak, 1988) Amygdala Becomes “irritable”, Increasingly sensitive to triggers Prefrontal Cortex Frontal lobes shut down or decrease activity to ensure instinctive responding Thalamus Ability to perceive new information decreases Triggering Stimulus Bottom-Up Responses

76 Lateral Ventricles Measures in an 11 Year Old Maltreated Male with Chronic PTSD, Compared with a Healthy, Non-Maltreated Matched Control (De Bellis et al., 1999)

77 Between Stimulus and Response Stimulus S Stimulus Sensory Thalamus Amygdala Cortex Very Fast Slower Hippocampus Response (LeDoux, 1996)

78 Between Stimulus and Response Stimulus S Stimulus Sensory Thalamus Amygdala Very Fast Slower Response Cortex Hippocampus Neuroregulatory Intervention Psychotherapy Psychopharmacology Social Environmental Intervention (LeDoux, 1996) In between stimulus and response, there is a response, in that space lies our power to choose our response, in our response lies our growth and freedom. Viktor Frankl

79 Serum Cortisol Cortisol Response to a Cognitive Stress Challenge in PTSD Related to Childhood Abuse Finding: There were elevated levels of cortisol in both the time period in anticipation of challenge (from time 60 to 0) and during the cognitive challenge (time 0–20). PTSD patients and controls showed similar increases in cortisol relative to their own baseline in response to the cognitive challenge. (Bremner, Vythilingam, et al 2002)


81 St. Aemilian-Lakeside Video about a trauma-informed program for children with emotional and behavioral problems St. Aemilian-Lakeside Trauma-Informed Care Slide 81

82 The Four R’s Realizes widespread impact of trauma and understands potential paths for recovery Realizes Recognizes signs and symptoms of trauma in clients, families, staff, and others involved with the system Recognizes Responds by fully integrating knowledge about trauma into policies, procedures, and practices Responds Seeks to actively Resist re-traumatization. Resists A trauma-informed program, organization, or system: Slide 82

83 Gender Differences in PTSD Raul Almazar Almazar Consulting

84 Olff, Langeland et al Gender Differences in PTSD 2007, Psychological Bulletin

85 MaleFemale Rate of Exposure60.7%51.2% Rate of Developing PTSD8.1%20.4% Types of TraumaMore susceptible to negative effects of childhood neglect Greater exposure to traumas that have high rates of PTSD More than 1/3 of women experienced intimate partner violence within the past 12 months More susceptible to negative effects of sexual abuse More exposure at a younger age Prior TraumatizationNo difference

86 MaleFemale Cognitive Appraisal Higher levels of perceived control Lower reliance on blaming others More likely to report threat and loss appraisals More likely to appraise events as stressful Higher perceived distress loss of personal control and lack of available coping strategies Pick up on threat signals more readily

87 MaleFemale Coping Instrumental Mastery Fight or Flight Tend and Befriend Freezing Passive avoidance Perry’s theory Psychological and Biological Response Are more sensitized to physiological heyperarousal systems – conduct disorder, ADD, antisocial - Higher SNS activity More sensitized to dissociated systems – anxiety, physical complaints, withdrawal HPA dysregulation - Oxytocin - Estrogen Endogenous Opioids

88 MaleFemale Health OutcomesMore aggressive behaviors Higher PTSD rates More anxiety, depressive disorders, somatization, alcohol and drug use

89 How Our Bodies Respond to a Real or Perceived Threat or a Trigger Hypothalamus-Pituitary-Adrenal Axis (HPA) Brings body into balance – Sympathetic Nervous System Fight, Flight or Freeze – Heart rate – Sweat response – Energy increase

90 Our Body’s Chemical Response Cortisol – Regulation of the Adrenalines – Increase of energy Adrenalines – Fight or flight – Sharpens our focus and stimulates memory – Increases blood pressure and heart rate – Shunts blood away from systems that are not needed in danger response to the brain and muscles

91 Our Body’s Chemical Response 2 Our natural Opioids – Prevents experiencing the pain – prevents memory consolidation Oxytocin – Inhibits memory consolidation Vasopressin – Prevents dehydration

92 Biochemical changes during and after the traumatic event Adrenaline - levels are chronically increased resulting in constant hyperstress and inability to distinguish danger signals – Inability to sleep, flashbacks, trouble with concentrating – Shuts off the brain

93 Biochemical changes during and after the traumatic event 2 Cortisol- Chronically low or high levels - results in reduced immune functioning, impaired regulation of the adrenalines, and damage to passages in the brain responsible for memory – While high, cortisol, thins stomach lining and bones, impairs the immune system, decreases blood flow to the intestines.

94 Gender Differences in the Trauma Response Females - tend to dissociate and paradoxically, trauma bond Males - fight or flee, exert power and control However - Both sexes will experience power and control and difficulties with species preservative behavior if the traumas and/or triggers continue too long

95 Gender Differences in Trauma Response 2 Females - Tend and Befriend – Shelley Taylor, UCLA The role of our hormones – Estrogen amplified the effects of oxytocin – Androgens diminish the effects of oxytocin

96 Creating Positive Cultures Trauma Informed Workforce Development Raul Almazar, RN, MA Senior Consultant SAMHSA’s National Center for Trauma Informed Care

97 Some Stressors:  Fiscal and funding cuts  Downsizing/organizational changes/ mergers  DIfferent payor systems  Regulatory changes  Role changes  Reimbursement changes  Do more with less  Practice changes  New metrics  Natural organizational events

98 Impact on the Individual  Loss of meaning and purpose  Decreased creativity  Inability to innovate  Absenteeism  Retreating into the familiar  Distracted, unfocused  Physical health effects

99 Organizational Impact  Turnover  Workers Compensation  Loss of market advantage  Decreased productivity  Creation of additional positions to supplement lagging productivity  Increased training costs  With an unhappy workforce - more susceptible to litigation  Sustained stress response imbedded in the organizational culture

100 2009 GALLUP POLL E MPLOYEE E NGAGEMENT I NDEX 33% - Engaged in their jobs 49% - Are not Engaged 18% - Actively Disengaged

101 Trauma lives in the body. The body has ways to indicate to us that a threat cue is perceived. Biological

102 Stress/Trauma Lives in the Body A chronic overreaction to stress overloads the brain with powerful hormones that are intended only for short-term duty in emergency situations. Serum cortisol levels Chronic hyperarousal – nervous system does an amazing job of preparing the individual to deal with the stress but:

103  Growth, reproduction and immune system all go on hold  Leads to sexual dysfunction  Increases chances of getting sick  Often manifests as skin ailments  Increases permeability of the blood brain barrier  Dr. Robert Sapolsky: “Why Zebras Don’t Get Ulcers” – study on salmon

104 More on changes as the result of too much stress Chronically high cortisol levels – Insulin resistance, poor sleep patterns – reinforces bad eating habits – no energy to exercise – Can produce cytokines, a protein that promotes inflammation – linked to heart disease, depression, arthritis and fibromyalgia – Impacts regulation adrenalines – implications for hippocampus and addiction

105 SAMHSA’s Six Key Principles of a Trauma- Informed Approach Slide 105 Safety Trustworthiness and Transparency Peer Support Collaboration and Mutuality Empowerment, Voice, and Choice Cultural, Historical, and Gender Issues

106 Principle 1: Safety Throughout the organization, staff and the people they serve, whether children or adults, feel physically and psychologically safe. Video: Leah HarrisLeah Harris Slide 106

107 Who Defines Safety? For people who use services: “Safety” generally means maximizing control over their own lives For providers: “Safety” generally means maximizing control over the service environment and minimizing risk Slide 107

108 Principles of TIC: SAFETY Raul Almazar, RN, MA SAMHSA National Center for Trauma Informed Care National Association of State Mental Health Program Directors Contact info:

109 Safety Throughout the organization: Staff and the people they serve (children and adults)  Feel physically safe  Feel psychologically safe  Physical setting is safe  Interpersonal interactions promote a sense of safety  Safety as defined by the people served

110 Four Types of Safety Adapted from Sandra Bloom’s Sanctuary Model:  Physical Safety  Psychological Safety  Moral Safety  Social Safety

111 Physical Safety  Sense of being safe, living in a physically safe space  Physical/Biological Safety  Good health practices  Occupational security and sound financial management ( Core TIA Principle: Trustworthiness and Transparency)

112 Psychological Safety  Sense of mastery over one’s life  Living in a world that has some predictability  Ability to express ones’ creativity  Self-efficacy  Presence of structure and organization within which one can try new ideas  Ability to make sense of what has happened/is happening

113 Moral Safety  Having a sense of meaning and purpose  Sense of hope and empowerment (Core TIA Principle: Empowerment, Voice and Choice)  Firm belief in Recovery, Recovery as a moral imperative ( Core TIA Principle: Peer Support)  Sense of integrity, courage and justice  Providing and receiving the most effective treatment  Attending to power differentials to promote health and healing (Core TIA Principle: Collaboration and Mutuality  Practicing democratic principles

114 Social Safety  Sense of feeling secure, cared for, trusted  Ability to express oneself  Ability to be safe with other people  Acceptance of differences and diversity ( Core TIA Principle: Cultural/Historical/Gender sensitivity)

115 Psychosocial Safety Climate The shared belief held by workers that their psychological safety and well-being is protected and supported by senior management. Defined as an organization or team level construct that refers to policies, practices and procedures that are upheld by managers and leaders for the protection of worker psychological health and safety (Dollard and Bakker, 2010)

116 ORGANIZATIONAL Climate vs. Culture Organizational Climate – shared perceptions of policies, practices and procedures present within an organization. (Reichers & Schneider, 1990) Observable manifestations of the organization Organizational Culture - underlying core values of an organization that are inherent, rather than observable. ( Bochner, 2003)

117 Security vs. Safety Security surrounds, but safety enfolds. Perhaps the lingering differences between the words can be found in their differing etymologies. Safe comes from Latin salvus, “uninjured, healthy. It’s related to salus, “good health.” Secure comes from Latin securus, “without care,” from se, “free from,” and cura, “care.”

118 To my mind, security suggests freedom from worries that derive from knowing that certain external safeguards are in place and that I can rely on them to protect me and my property. Safety is a richer word that includes an inner certainty that all is well. In a sense, security is external, while safety is internal. From Maeve Maddox, Writing Tips, Academic Generalist

119 Risk Management Risk management is the identification, assessment, and prioritization of risks followed by coordinated and economical application of resources to minimize, monitor, and control the probability and/ or impact of unfortunate events or to maximize realization of opportunities. (ISO31000)

120 Establishing the Context To establish the context means to define the external and internal parameters that organizations must consider when they manage risk. ISO expects you to consider your organization’s context when you define the scope of its risk management program, when you formulate its risk management policy, and when you establish its risk criteria.

121 External Context An organization’s external context includes all of the external environmental parameters and factors that influence how it manages risk and tries to achieve its objectives. It includes its external stakeholders, its local, national, and international environment, as well as key drivers and trends that influence its objectives. It includes stakeholder values, perceptions, and relationships, as well as its social, cultural, political, legal, regulatory, financial, technological, economic, natural, and competitive environment.

122 Internal Context An organization’s internal context includes all of the internal environmental parameters and factors that influence how it manages risk and tries to achieve its objectives. It includes its internal stakeholders, its approach to governance, its contractual relationships, and its capabilities, culture, and standards.

123 Managing Risk ISO 31000:2009 gives a list on how to deal with risk: Avoiding the risk by deciding not to start or continue with the activity that gives rise to the risk Accepting or increasing the risk in order to pursue an opportunity Removing the risk source Changing the likelihood Changing the consequences Sharing the risk with another party or parties (including contracts and risk financing) Retaining the risk by informed decision

124 Examples Failure Mode Effects Analysis (FMEA) Suicide Accidental Death Personal Safety Device Strategic Plan


126 Principles of TIC: Peer Perspectives on Safety Malcolm Aquinas, MAT SAMHSA National Center for Trauma Informed Care National Association of State Mental Health Program Directors Contact info:

127 “Creating safety is not about getting it right all the time; it’s about how consistently and forthrightly you handle situations with a client when circumstances provoke feelings of being vulnerable or unsafe. Honest and compassionate communication that conveys a sense of handling the situation together generates safety.” -SAMHSA TIP 57

128 Safety Generalize safety concerns from the Peer Perspective across two broad areas Responsiveness – Applies to behavioral health services and systems Competence – Applies to providers of services within those systems

129 Six Safety Considerations 1.Environment 2.Meetings 3.Predictability 4.Reliability 5.Dependability 6.Transparency

130 Environment Allow us to choose our own seat Provide easy access to exits Communicate clearly and supportively that we have free egress from rooms Express empathetic support without strong emotions Remember that our senses (sight, sound, smell, taste, and touch) are vigilantly searching for possible threats

131 Meetings What is the content under discussion? In what context is it being presented? How much information is being presented? In what amount of time is the information being presented? How many people are presenting the information? What is potentially triggering? In what ways was the individual supported to prepare for the material?

132 Predictability Who interacts with us? How do they present themselves? What schedules exist? How confidently can we move around in our environment?

133 Reliability Do you follow through on things you commit to do? Do you accomplish tasks in the agreed upon timeframe? If you cannot complete an agreed upon task, either at all or in the timeframe agreed to, do you communicate that information to us with the reasons why?

134 Dependability Is there someone we can go to for support? Are they available when we need them? Are they trustworthy?

135 Transparency Are we included in the decision-making process? Is information related to our treatment and care communicated in a timely manner, by people we trust, in a way we can understand it? Are we provided opportunities to ask questions in a retaliation-free environment? Do providers understand how critical this is for us if trust is to be established?

136 Je ne sais quoi Openness – Be inviting and welcoming Honesty – Speak truthfully Compassion – Demonstrate active kindness Empathy – Validate personally Genuineness – Be present Transparency – Pull back the curtain Vulnerability – Show that this matters

137 “You’ve seen my descent. Now watch my rising.” ~Rumi Always Remember: 1.It’s what happened to us, not what’s wrong with us; and 2.We may be stuck, but we are not broken.

138 Reducing Risk, Creating Safety Together Leah Harris, MA SAMHSA National Center for Trauma Informed Care National Association of State Mental Health Program Directors Contact info:

139 Redefining Risk Issues of safety and risk come up particularly around suicide and self-harm, which are often trauma responses. Suicide risk increases with ACE score (Felitti et al, 1998). Trauma informed approaches emphasize the primacy of healing in mutual relationships. Traditional forms of assessment and liability fears interfere with these relationships. Dynamics of power and control take away from trauma- informed care and approaches to suicide prevention and intervention.

140 Responses to my suicidality As a trauma survivor with a history of intense suicidal feelings and self-harm, I was never given the space to make sense of these feelings in traditional settings. Responses: Police response – carted away in handcuffs Being punished with loss of privileges for self-harming on the ward Threatened with interventions I didn’t want No one asked “what happened to you?” Consequently, I learned to hide my suicidal thoughts and feelings and self-harming behaviors.

141 Safety as a Euphemism for Control Safety is one of our deepest human needs. In many human service settings, people who are suicidal can experience unwanted, traumatic, and humiliating interventions, all in the name of “safety.” We need to understand that in this context, safety is a euphemism for “control.” Shery Mead talks about “fear-based” vs. “hope-based” responses to suicide. Many people in human service fields have been trained not to acknowledge this fear to themselves or the other person, and move directly into “control mode.”

142 Liability Drives the System “If we don’t rethink the notion of risk, the liability issue will continue to drive what we do.” - Shery Mead

143 Safety Contracts: Not Safe Safety contracts are usually developed to address the provider or support person’s fear and agency fears of liability Safety contracts are inherently coercive and not in line with trauma informed care “Signing a safety contract rather than talking about the painful feelings is just another way of generating powerlessness.” Shery Mead Signing a no-suicide contract should not be used in a coercive way, or as a condition for the person to keep receiving support.

144 Ways of Approaching Shared Risk: Crisis and Safety Planning In a mutual support relationship, responses to crisis are negotiated together in advance of a crisis happening. Crisis planning: one approach is to have a plan for how to address risk and dangerousness in advance. When you ask the question, you can figure out a response together pro-actively. This approach is trauma-informed and respects a person’s wishes for dignity and respect. Replace the safety contract with a safety plan. Developing a plan for next steps for self-care, support, etc. is important, but it should be a collaborative process that the person experiencing the suicidal feelings has said would be helpful

145 Authenticity Traditional treatment relationships discourage the support person’s authentic expression of their own feelings. Trauma-informed relationships are a two way street. Trauma-informed practitioners learn to recognize within themselves the desire to control someone’s behavior out of fear. In such a scenario, it would be completely appropriate for a supporter to tell someone who is suicidal, “I have to be honest - hearing you talk about this feels scary for me. But I am willing to try to sit with these feelings as we talk.”

146 Authenticity Though suicidal feelings are common, talking about them is taboo. In the traditional provider-patient relationship, sharing about these personal experiences is discouraged. In a trauma-informed relationship, the peer practitioner discloses own past or current struggles with suicidal thoughts, when applicable. “I’ve felt that way, too.” Peer practitioners also share coping skills (strategies) they have found useful to manage their own suicidal thoughts or feelings. Trauma informed approaches facilitate learning and growth for both the support person and person in distress/crisis.

147 Emotional CPR to create safety Emotional CPR (eCPR) is a public health education program that promotes a trauma-informed approach to supporting people in crisis and distress. The most important thing we can do as eCPR practitioners is to develop an authentic, heart-to-heart connection with a person experiencing suicidal thoughts or feeling unsafe in any way. When a relationship begins with trying to check off items on an assessment/screening form, it is much harder to establish that authentic connection.

148 Emotional CPR to create safety When practicing eCPR, we drop the traditional assessment agenda (e.g. How long have you been suicidal? Do you have a plan?) and seek to build trust and understanding. We may ask questions of our own, but they are curious and open-hearted, such as: What has happened to cause you to feel this way? How can I support you right now? What do you need right now? Has anything or anyone helped you in the past when you’ve felt this way?

149 It’s about Mutual Relationships Even when people don’t have shared experiences, building mutually empathic relationships is the only way that people can build a “new, shared” story. - Shery Mead “Creating a new, shared story involves a willingness to take risks in relationship even when we are uncomfortable with the situation.” Shery Mead Learning from crisis: we can share what we have learned in the wake of a crisis, and use those learning to create a new crisis plan that will help prevent future crises and offer us more opportunities for healing and growth.

150 Resources Defining Outcomes for Crisis Response by Shery Mead and Eric Kuno: Crisis and Connection by Shery Mead and David Hilton Peer Support: What Makes it Unique? by Shery Mead and Cheryl MacNeil: Intentional Peer Support: Emotional CPR:

151 Discussion Do staff feel safe in your organization? Why or why not? Do the people served feel safe? How do you know? What changes could be made to address safety concerns? Slide 151

152 Principle 2: Trustworthiness and Transparency Organizational operations and decisions are conducted with transparency and the goal of building and maintaining trust among clients, family members, staff, and others involved with the organization. Video: Pat RisserPat Risser Slide 152

153 Examples of Trustworthiness Making sure people really understand their options Being authentic Directly addressing limits to confidentiality Slide 153

154 Discussion How can we promote trust throughout the organization? Do the people served trust staff? How do you know? What changes could be made to address trust concerns? Slide 154

155 Principle 3: Peer Support Peer support and mutual self-help are key vehicles for establishing safety and hope, building trust, enhancing collaboration, serving as models of recovery and healing, and maximizing a sense of empowerment. Video: Cicely SpencerCicely Spencer Slide 155

156 Examples of Peer Support Peer support = A flexible approach to building mutual, healing relationships among equals, based on core values and principles: Voluntary Non- judgmental RespectfulReciprocalEmpathetic Slide 156

157 Discussion Does your organization offer access to peer support for the people who use your services? If so, how? Does your organization offer peer support for staff? What barriers are there to implementing peer support in your organization? Slide 157

158 Principle 4: Collaboration and Mutuality Partnering and leveling of power differences between staff and clients and among organizational staff from direct care to administrators; demonstrates that healing happens in relationships, and in the meaningful sharing of power and decision- making. Everyone has a role to play; one does not have to be a therapist to be therapeutic. Slide 158

159 Examples of Collaboration “There are no static roles of ‘helper’ and ‘helpee’—reciprocity is the key to building natural community connections.”—Shery Mead Hospital abolished special parking privileges and opened the “Doctor’s Only” lounge to others Models of self-directed recovery where professionals facilitate but do not direct Direct care staff and residents in a forensic facility are involved in every task force and committee and are recognized for their valuable input Slide 159

160 Discussion Can you think of examples from your agency of true partnership between staff and people served? What about partnership between top-level administrators and line staff? Can you think of changes that would significantly decrease the power differentials in your agency? Slide 160

161 Principle 5: Empowerment, Voice, and Choice Individuals’ strengths and experiences are recognized and built upon; the experience of having a voice and choice is validated and new skills developed. The organization fosters a belief in resilience. Clients are supported in developing self-advocacy skill and self-empowerment Video: GAINS Center Interview VideoGAINS Center Interview Video Video: William KellibrewWilliam Kellibrew Slide 161

162 Examples Asking at intake: “What do you bring to the community?” Treatment activities designed and led by hospital residents Murals on walls painted by staff and residents Turning “problems” into strengths Slide 162

163 Discussion Question Slide 163 How can you use your clients’ strengths?

164 Discussion Can you think of examples from your work setting of empowerment, voice and choice for people served? What about for staff? Can you think of policies or practices that do the opposite—that take voice, choice, and decision-making away? Could any of these things be changed? Slide 164

165 Principle 6: Cultural, Historical, and Gender Issues The organization actively moves past cultural stereotypes and biases, offers gender-responsive services, leverages the healing value of traditional cultural connections, and recognizes and addresses historical trauma. Video: Iden CampbellIden Campbell Slide 165

166 Examples: A Place of Healing Hawaii women’s prison builds a trauma- informed culture based on the Hawaiian concept of pu`uhonua, a place of refuge, asylum, peace, and safety. Video: TEDx Talk by Warden Mark PattersonTEDx Talk by Warden Mark Patterson Slide 166

167 Traumatic Reminders Loss of Control Power Differential Lack of Predictability

168 I've learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel. ~ Maya Angelou

169 Almazar Consulting SAMHSA’s National Center for Trauma Informed Care

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