2Trauma Informed System of Care: Changing Our Perspective Raul Almazar, RN, MASenior ConsultantNational Center for Trauma Informed CareAlmazar Consulting
3What 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 disastersDSM IV-TR (APA, 2000)Person’s response involves intense fear, horror and helplessnessExtreme stress that overwhelms the person’s capacity to copeAlmazar Consulting
4Events/circumstances cause trauma. The Three E’s in TraumaEventsEvents/circumstances cause trauma.ExperienceAn individual’s experience of the event determines whether it is traumatic.EffectsEffects of trauma include adverse physical, social, emotional, or spiritual consequences.The focus on events places the cause of trauma in the environment not in some defect of the individual. This is what underlies the basic credo of trauma-informed approaches: “It’s not what’s wrong with you, but what happened to you.”The focus on experience highlights the fact that not every child or adult will experience the same events as traumatic.The identification of a broad range of potential effects reminds us that our response must be holistic—it’s not enough to focus on symptoms or behaviors. Our goal is to support a child to learn and grow or an adult to live a satisfying life.
5Traumatic Events: render victims helpless by overwhelming force; 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
6Effect of TraumaThe effect of trauma on an individual can be conceptualized as a normal response to an abnormal situation.The effect of trauma on an individual can be conceptualized as a normal response to an abnormal situation.
7DEFENDING CHILDHOOD PROTECT HEAL THRIVE REPORT OF THE ATTORNEY GENERAL’S NATIONAL TASK FORCE ON CHILDREN EXPOSED TO VIOLENCENOV 2012almazarconsulting.com
8Prevalence80% 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.almazarconsulting.com
9EffectsTheir 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.almazarconsulting.com
10National Child Abuse Statistics 2011 (Childhelp.org) 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
11National 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
12National 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
14What 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 settingsThere 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)Traumatic exposure is epidemic among adults and children in the mental health system. And as Gilligan and Garbarino’s work illustrates, there appears to be a relationship between being a victim and victimizer.Almazar Consulting
15Therefore ...We need to presume the clients we serve have a history of traumatic stress and exercise “universal precautions”(Hodas, 2004)Because we will never know someone’s full life experience, it makes sense to presume everyone in our care has a history of trauma and adopt a “universal precautions” approach.Almazar Consulting
16Prevalence 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
17Avoidance of Shame and Humiliation The basic psychological motive or cause of violent behavior is the wish to ward off or eliminate the feelings of shame and humiliation – a feeling that is painful and can even be intolerable. Our task is to replace it with a feeling of pride. Hodas, 2004
18Trauma Sensitive Person Served Trauma Assessment And Treatment Almazar Consulting
21ACE StudyCompares adverse childhood experiences against adult status, on average, a half century laterAlmazar Consulting
22ACE 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
23Other Critical Trauma Correlates: The Relationship of Childhood Trauma to Adult Health Adverse Childhood Events (ACEs) have serious health consequencesAdoption of health risk behaviors as coping mechanismseating disorders, smoking, substance abuse, self harm, sexual promiscuitySevere medical conditions: heart disease, pulmonary disease, liver disease, STDs, GYN cancerEarly Death (Felitti et al., 1998)Almazar Consulting
24Adverse Childhood Experiences Recurrent and severe physical abuseRecurrent and severe emotional abuseSexual abuseGrowing up in household with:Alcohol or drug userMember being imprisonedMentally ill, chronically depressed, or institutionalized memberSeparation/DivorceMother being treated violentlyBoth biological parents absentEmotional or physical abuse(Fellitti,1998)Almazar Consulting
25ACE 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
26ACE Questions: Con’t5. 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
27The higher the ACE Score, the greater the likelihood of : Severe and persistent emotional problemsHealth risk behaviorsSerious social problemsAdult disease and disabilityHigh health and mental health care costsPoor life expectancyFor 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 6/2007I am going to skim through a few slides as examples( Presenter must determine slides to skirt over or even delete – depending on time allowed for the presentation.)During presentation of these slides – be sure to occasionally point out the obvious graded relationship between the # of ACE categories experienced in childhood - and the adult problem being shown. Eg. The slide on rape – “note how the greated numbers of Adverse childhood experiences in childhood is linked to the rise in the chances of being raped as an adolescent or adult” – or with the slide on alcoholism, “look at how, with more and more accumulation of adverse childhood experiences shown across the bottom of the chart – it is more and more likely that when these children become adults, they will abuse alcohol”. I use a laser pointer to draw audience eyes toward what I am pointing out on the bargraph slide.
28Adverse Childhood Experiences are Common Of the 17,000 HMO Members:1 in 4 exposed to 2 categories of ACEs1 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.It is important to recognize that Adverse Childhood Experiences are Common. First, The 17,000 HMO members who were interviewed were middle class people, with jobs and medical insurance – not likely to have been exposed to street violence, extreme poverty, malnutrition, dislocation, natural catastrophes or war terror. Of 17,000 HMO members: 72% had attended college 77% were white 62% were 50 or older They are US.1 in 4 were exposed to 2 categories of ACE’s –which would equate to 1/4th of this audience1 in 16 were exposed to 4 categories22% were sexually abused as children. That’s over 20% of this audience. Over one in every 5 of us.66% of the women experienced abuse, violence or family strife in childhood. Two-thirds of the women in this audience more than likely had that experience as children.This is of epidemic proportions and indicates the need to address childhood trauma as a major public health issue.Almazar Consulting
29The ACE Comprehensive Chart Adverse Childhood ExperiencesNeurobiological Impacts and Health RisksLong-term Health and Social ProblemsThe 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
31Childhood Experiences Underlie Chronic DepressionAdults with an ACE score of 4 or more were 460% more likely to be suffering from depression .The bargraph may underestimate chronic depression in men. Men tend to be covert (rather than overt) in disclosing feelings of depression. A recent study of men found 85% to be suffering from “Alexathymia” – a new DSM category of Depression for men.Almazar Consulting
32Childhood Experiences Underlie Suicide 4+The likelihood of adult suicide attempts increased 30-fold, or 3,000%, with an ACE score of 7 or more.Childhood and adolescent suicide attempts increased 51-fold, or 5,100% with an ACE score of 7 or more.This is hugely significant. Relationships of this magnitude are rare in epidemiology.Suicidality may be triggered (by one more event – cumulative) but is not usually Caused by “mental illness”, drugs, rejection by peer groups, school pressure, failures, etc.Rather, it is an attempt to cope – a way to manage or escape from the overwhelming impacts of adverse childhood experiences and/or adult trauma.Its easier to get to 7 ACEs than you might think……(Anna’s ACE’s – sexual abuse; physical abuse; emotional abuse; my substance abuse, abandonment (temporary); bitter separation and divorce; my depression to 1 suicide attempt; attachment/nurturance issues….)In a family where there is domestic violence for example – there often exists additional problems or ACE categories such as substance abuse, drug use, separation/divorce, abandonment, physical abuse, sexual abuse, someone in correctional system, serious emotional problems e.g. depression, emotional abuse, neglect………..Once an individual experiences 1 significant ACE – it opens him or her to more – creates fragility, compromises resiliency. Like an immune system gets compromised. This is part of the story of what happened to my daughter.We may keep ourselves socially or even professionally safe or acceptable by not looking at childhood experiences when we address suicide.321Almazar Consulting
33Childhood Adverse Experiences 2/3rd (67%) of all suicide attempts64% of adult suicide attempts80% of child/adolescent suicide attemptsAre Attributable toChildhood Adverse ExperiencesACE study analysis found 2/3rd of ALL suicide attempts; 64% of ADULT suicide attempts, and a startling 80% of child/adolescent suicide attempts to be attributable to cumulative childhood traumas.The study also found the lifetime prevalence of having at least 1 suicide attempt was approximately 3 times higher for women than for men. (5.4% vs 1.9%)However, we know from other research studies of the general population, that men are 4 times as likely as women to actually take their own lives.Early adverse childhood experiences [ACEs] dramatically increase the risk of suicidal behaviors. ACEs have a strong, graded relationship to suicide attempts during childhood/adolescent and adulthood. An ACE score of 7 or more increased the risk of suicide attempts 51-fold among children/adolescents and 30-fold among adults (Dube et al, 2001). In fact, Dube and colleagues commented that their estimates of population attributable fractions for ACEs and suicide are “of an order of magnitude that is rarely observed in epidemiology and public health data.” Nearly two- Further, while system responses to family violence continue to place greater emphasis on physical forms of abuse, the strongest predictor of future suicide attempts in ACE research was emotional abuse.t two hirds (64%) of suicide attempts among adults were attributable to ACEs and 80% of suicide attempts during childhood/adolescence were attributed to ACEs. Women are 3 times as likely as men to attempt suicideMen are 4 times as likely as women to complete suicide.
34ACE Score and Hallucinations Compared to persons with 0 ACEs, those with 7 or more ACEs had a five-fold increase in the risk of reporting hallucinations Whitfield et al 2005Abuse and trauma suffered in the early years of development resulted in a far greater likelihood of pre-psychotic and psychotic symptoms. Perry, B.D. (1994)In an adult inpatient sample, 77% of those reporting CSA or CPA had one or more of the ‘characteristic symptoms’ of schizophrenia listed in the DSM-IV: hallucinations (50%); delusions (45%) or thought disorder (27%) Read and Argyle 1999Ever Hallucinated* (%)ACE Score*Adjusted for age, sex, race, and education.Almazar Consulting
35ACE Score and Impaired Memory of Childhood Percent With MemoryImpairment (%)Amnesia, usually considered a theatrical device of Hollywood movies of the 1940s, is in fact alive and well, though unrecognized, in everyday medical practice. In Kaiser’s Weight Program, they found 12% of the participants were partially or sometimes totally amnesiac for a period of their lives, typically the few years before weight gain began. In the ACE Study, they found that there was a distinct relationship of ACE Score to impaired memory of childhood, and understand this phenomenon to be reflective of dissociative responses to emotional trauma.ACE ScoreAlmazar Consulting
36Health Risk Behaviors Almazar Consulting Developed in response to neurological impacts and pain of childhood adverse experiences.Almazar Consulting
37Adverse Childhood Experiences and Current Smoking %A child with 6 or more categories of adverse childhood experiences is 250% more likely to become an adult smoker .Smoking may not be caused by existence of vending machine or genetic predispositionA person with 4 categories of adverse childhood experiences is 260% more likely to have Chronic Obstructive Pulmonary Disease (COPD) .Almazar Consulting
38Childhood Experiences and Adult Alcoholism 4+3A 500% increase in adult alcoholism is directly related to adverse childhood experiences.2/3rds of all alcoholism can be attributed to adverse childhood experiencesThis certainly suggests that alcoholism, contrary to popular belief, may not be simply a disease – but rather be a means by which the individual has learned to ease the pain of the trauma – or to balance his/her nervous system – e.g. sooth anxiety.Important ALWAYS to address and treat trauma along with alcoholism.21Almazar Consulting
39ACE Score and Intravenous Drug Use A male child with an ACE score of 6 has a 4,600% increase in the likelihood that he will become an IV drug user later in life78% of drug injection by women can be attributed to ACEsKeep in mind Relationships of this magnitude are rare in Epidemiology.N = 8, p<0.001Almazar 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
41Is drug abuse self-destructive or is it a desperate attempt at self-healing, albeit while accepting a significant future risk?” (Felitti, 1998)Almazar Consulting
42Significant implications for medical practice and treatment programs Basic cause of addiction is experience-dependent, not substance-dependentSignificant implications for medical practice and treatment programsACE study data Suggests the basic cause of addiction is predominantly experience-dependent during childhood and not substance-dependent. ACE study also demonstrates MANY adult conditions may be experience dependent during childhood. This challenge to the usual concept of the cause of addictions – and other disorders - has significant implications for medical practice and for treatment programs.Existing practice commonly asks “What is wrong with the person?”, vs “What happened to this person?” Existing practice observes symptoms, develops diagnoses, and treats symptoms instead of underlying causes.To treat symptoms while not treating underlying causes, is like attending to smoke, instead of fire. It may be – in fact the research indicates – that when substance abuse is treated concurrently with trauma, relapse rates decrease.These kinds of public health problems, while indeed that, are often also unconsciously attempted solutions to major life problems harkening back to the developmental years. The idea of the problem being the solution, while understandably disturbing to many, is certainly in keeping with the fact that opposing forces routinely co-exist in biological systems.Understanding that it is hard to give up something that almost works, particularly at the behest of well-intentioned people who have little understanding of what has gone on, provides us a new way of understanding treatment failure in addiction programs where typically the solution rather than the core problem is being addressed.Almazar Consulting
44Childhood Experiences Underlie Rape 4+32Repetition of original trauma. Victims of cumulative early childhood traumas that have never been addressed - are much more highly vulnerable than others to being revictimized by rape or by domestic violence.Women with an ACE score of 4+ are 500% more likely to become victims of domestic violence.They are almost 900% more likely to become victims of rape.1Almazar Consulting
45ACEs Underlie Domestic Violence 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 violenceWomen with an ACE score of 4+ are also 500% more likely to become victims of domestic violence.Just as the risk of becoming a VICTIM of domestic violence rises with the number of ACES – So does the risk of perpetrating domestic violence. Also true for both women and men.
46The more adverse experiences as a child, the higher the risk of becoming a victim of domestic violence. This is the case for both women and men.Almazar Consulting
47Just as the risk of becoming a VICTIM of domestic violence rises with the number of ACES – So does the risk of perpetrating domestic violence. Also true for women and men.Almazar Consulting
48Adverse Childhood Experiences and Likelihood of > 50 Sexual Partners Higher # of ACEs more likelihood of the adult having had 50 or more sexual partners and being at risk for unwanted pregnancy, socially transmitted diseases, HIV/AIDs.Almazar Consulting
49ACE Score and Unintended Pregnancy or Elective Abortion Higher ACE score leads to increased unintended pregnancy (red) or Elective Abortion (yellow)Almazar Consulting
50Adverse Childhood Experiences and History of STD There is a significant graded relationship between Adverse Childhood Experiences and the rate of STDs. (Sexually Transmitted Diseases)(Info: STDs include Chlamydia, gonorrhea, Genital Herpes, HPV (Human Papillomavirus Infection), PID (Pelvic Inflammatory Disease), Syphilis, Trichomoniasis), HIV/AIDS (Human Immunodeficiency Virus and Acquired Immunodeficiency Syndrome.Some above STDs Can lead to infertility.)Almazar Consulting
51Sexual Abuse of Male Children and Their Likelihood of Impregnating a Teenage Girl1.8x1.4x1.3x1.0 refPercent who impregnateda teenage girlBoys who were sexually abused are more likely to impregnate a teenage girl.The earlier the age when the boy was sexually abused – the greater the likelihood that he will impregnate a teenage girlNot yrs yrs <=10 yrsabused Age when first abusedAlmazar Consulting
52Pink =self Green =mother 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 PregnancyPink =selfGreen =motherPercent who had ateen pregnancyThis is about the relationship of violence (to self or to mom) and getting pregnant.The more frequently girls are pushed, grabbed, slapped, shoved, or had something thrown at themselves or at their mothers – the greater the likelihood the girls will have a teen pregnancy.Never Once, Sometimes Often VeryTwice oftenAlmazar Consulting
53ACE Score and Indicators of Impaired Worker Performance Prevalence of Impaired Performance (%)The higher the ACE score the harder time an individual may have in making a living. Here there is a graded relationship between ACE scores Absenteeism, Serious Financial Problems and Job ProblemsAlmazar Consulting
54“What’s wrong with you?” “What happened to you?”instead of“What’s wrong with you?”Almazar Consulting
55From “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?
56Trauma Symptoms = Tension Reducing Behaviors “How do I understand this person?”rather than“How do I understand this problem or symptom?”A trauma-informed approach shifts the focus to the individual and away from some particular and limited aspect of his or her functioning. A holistic and trauma-focused understanding gives people a structure for organizing and understanding their experience.Developmental factors: Disruption of developmental tasks in childhood can result in adaptive behavior, which may be interpreted in the mental health system as "symptoms” such as:Disrupted self-soothing can be labeled as agitationDisrupted ability to see the world as a safe place looks like paranoiaDistrust of others can be interpreted as paranoia (even when based on experience)Disruptions in organized thinking for decision-making appears as psychosis
57All behavior has meaning Symptoms are ADAPTATIONS Comfort vs. Control We build on success not deficitsAlmazar Consulting
59What’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.
60Please 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.
616. 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.
6211. 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”?)
63Attachment & Belonging Community, Culture, Spirituality CapabilityIntellectual & employable skillsSelf regulation – self control, executive function, flexible thinkingAbility to direct & control attention, emotion, behaviorPositive self view, efficacyAttachment & BelongingBonds with parents and/or caregiversPositive relationships with competent and nurturing adultsFriends or romantic partners who provide a sense of security & belongingCommunity, Culture, SpiritualityFaith, hope, sense of meaningEngagement with effective orgs – schools, work, pro-social groupsNetwork of supports/services & opportunity to help othersCultures providing positive standards, expectations, rituals, relationships & supportsKEY SYSTEMS FORResilienceNourishmentProtectionCommunity, culture and spirituality provide human beings with belonging, faith, hope, and a sense of meaning. People living in high capacity communities are less likely to have high Adverse Childhood Experience scores, less drug and alcohol abuse, less depression and serious and persistent mental illness, and fewer problems in school and at work. In the following slides we’ll talk about many aspects of community as a system for guiding resilience. But first, let’s explore the two other systems that guide positive adaptation.Many people talk about the importance of people in their lives – people who recognize and encourage our unique talents, interests and strengths. Relationships with caring and competent people are vital. People who have difficulty with emotional regulation, picking up social cues, problems with addiction and family, and other consequences of developmental trauma, can be challenging friends and mentees. We have to be intentional about building competence in mentors, friends, neighbors, even marriage partners. Skill building, coaching, ability to consult with mental health professionals and other supports may be important supports that increase the likelihood that the relationship will last and contribute to resilience. Relationships that provide security and belonging can only occur when people have the skills and competencies to actually be supportive in times of stress and challenge as well as during celebration and repose.So what’s important in nurturing capabilities?Kids who learn to read fluently by age 10 do better throughout life. There is a great deal of research on why this is true and the findings vary, but learning to read fluently gives us all a stronger foundation for resilience. Knowing this might give us a clue about critical periods for making effective investments. We have to work with compassion for the experience that each child has had. For some children, extra teaching supports will be effective and the child will learn to read fluently. But, as you remember the brain science section of this course, you will recall that the brain’s adaptation to toxic stress can lead to an inability to read fluently – so we must be on the watch for each child’s core gifts. Perhaps a child who doesn’t learn to read fluently has extraordinary relational skills. In that case, adults can nurture those skills and help the child imagine a future in which joy, learning and prosperity are grounded in a relational environment, not an academic one.Self regulation is our ability to gauge what’s going on inside and to keep it under control in order to navigate a social situation. When we can’t—or don’t--read the situation and adapt our behavior to it, the social aspects of life become more difficult. There are a number of strategies for practicing self-regulation. Depending on the cultural environment, these might include belly breathing, practicing awareness of how thoughts are increasing or reducing anxious thoughts, prayer, and other calming practices can help. The states of Massachusetts and Washington are working with school personnel to develop compassionate teaching and discipline methods that help traumatized children and reduce non-academic barriers to success at school.Positive view lets me know I am important and valuable; it helps me to ask for help when I need it. It helps me not to give up. Learning to ask for help, accept help and show appreciation for help are important skills that we may be able to teach directly.Self-efficacy is the belief that what I do influences what happens to me. Trauma teaches us: “Danger can jump on you on any time, no matter what you do” so it’s hard to believe that individual behavior counts for something. That makes it very hard to answer a challenge with effort or to believe in yourself or others. Simple things do help build self efficacy, like giving children choices, assigning chores that have real value for the family or community, and encouraging a child to build skills that are complex and take time to develop. Self-efficacy is a good thing; but the truth is that none of us can control many of the things that happen to us. The death of a loved one, an accident or an unexpected opportunity might throw a wrench into our expectations. So, it’s important to develop relationships with people who help us to find a balance between knowing that our efforts are valuable, and accepting that some things are beyond our control.The most direct route to helping people to overcoming potential threats and adversities is to nurture these three systems throughout the lifespan.WholenessGrowth
64EXAMPLES OF PROGRAM & POLICY ACTIONS 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.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). (http://www.k12.wa.us/CompassionateSchools/default.aspx)There are many other examples of how organizations, communities and programs have put the ACE information to work effectively.For example, Parent Trust for Washington Children, which works with parents who have multiple issues, including substance abuse AND domestic violence OR abuse of their own children. These parents are court-ordered to treatment and they are court-ordered to parenting classes. It can be hard to make progress under those conditions. However, Parent Trust has begun to use ACE screen as a very effective tool. On the one hand they use ACEs to help parents understand the source of their own struggles and to motivate parents to prevent ACEs in their own children’s lives. On the other hand, they use ACE information to help predict and prevent relapse. Because people who suffer trauma during childhood can have a lower threshold where stress is experienced as crisis, parents with 4 or more ACEs are considered more vulnerable to relapse when facing certain kinds of stressors. They collect ACE data and other data quarterly and use that information to do relapse prevention. It’s extremely cutting edge work and just one example of how programs are thinking about the application of ACE findings.Another example of leading edge work is the Office of the Superintendent of Public Instruction’s Compassionate Schools Initiative. The Compassionate Schools Initiative within Learning and Teaching Support provides training, guidance, referral, and technical assistance to schools wishing to adopt a Compassionate Schools Infrastructure. Compassionate Schools benefit all students who attend but focus on students chronically exposed to stress and trauma in their lives. These schools create compassionate classrooms and foster compassionate attitudes of their school staff. The goal is to keep students engaged and learning by creating and supporting a healthy climate and culture within the school where all students can learn. Staff from The Learning and Teaching Support section of OSPI and Dr. Ray Wolpow at the Woodring College of Education at Western Washington University in Bellingham have co-written a 246 page handbook entitled The Heart of Learning and Teaching: Compassion, Resilience, and Academic Success. This publication is a great resource for schools wishing to adopt a compassionate approach to learning and teaching. It includes principles for working with children who have experienced traumatic stress:Offer Unconditional positive regard and encouragement.Always empower, never dis-empower.Required helpfulness: ask students to make regular contributions to the welfare of their families or support groups by helping others deal with common challenges.Increase connections between individuals and any pro-social person— family members, alternative caregivers, communities, peer groups, and school personnel – that can provide external support to foster resiliency.These principles are evident in the work of many whole communities, whether they be school communities, communities of faith, or geographic communities, who are changing the way people live with one another. Let’s take a look at the amazing success in the Port Gamble S’Klallam Tribe.
65Punishment vs. Compassion Killarney Secondary School – 2013Vandalism, false fire alarms, locker break-ins drug deals commonLincoln High School – 2011Kids kicked out of other schools, last chance; gangs controlled building.Discipline by Enforcement of Punishment, ObedienceZero Tolerance and no skill building to manage stressTotalitarian atmosphere, Fear, vigilance and mistrustRegard unruly behavior as willful disobedienceStudents feel like potential criminalsWhat’s wrong with this kid?Suspensions and absenteeism down 30%Discipline by Respect, Understanding, CompassionFair Consequences and skill building to manage stressAtmosphere of Safety and Trusting RelationshipsRegard unruly behavior as a manifestation of traumaStudents feel understood and treated fairlyWhat is happening with this kid?Suspensions and absenteeism down 87%Punishment vs. CompassionKillarney Secondary School 2010 – 2013Vandalism, false fire alarms, locker break-ins drug deals commonDiscipline by Enforcement of Punishment, ObedienceZero Tolerance and no skill building to manage stressTotalitarian atmosphere, Fear, vigilance and mistrustRegard unruly behavior as bad – willful disobedienceStudents feel like potential criminalsWhat’s wrong with – or bad about – this kid?Suspensions and absenteeism down 30 %; (late arrivals down 39%; graffiti gone, prank fire alarms gone)Lincoln High School 2009 – 2011Kids kicked out of other schools, last chance; emotional, physical, sexual abuse; gangs controlled building,Discipline by Respect, Understanding, CompassionFair Consequences and skill building to manage stressAtmosphere of Safety and Trusting RelationshipsRegard unruly behavior as a manifestation of traumaStudents feel respected and treated fairlyWhat is happening with this kid?Suspensions and absenteeism down 87%
66Neurodevelopment of Childhood Bruce D. Perry, M. D. , Ph. D. www Neurodevelopment of Childhood Bruce D. Perry, M.D., Ph.D.
67How Trauma Affects the Brain Experiences Build Brain ArchitectureServe & Return Interaction Shapes Brain CircuitryToxic Stress Derails Healthy DevelopmentTrauma affects the brain, especially the developing brain. This three-part video series from the Harvard University Center on the Developing Child and the National Scientific Council on the Developing Child depicts how advances in neuroscience, molecular biology, and genomics now give us a much better understanding of how early experiences are built into our bodies and brains.The playlist containing all three videos is available at
68The 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.
69The 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.
70The compartmentalization of Western life Separate by ageSeparate by wealthSeparate by workSeparate in education, by professionSeparate by transportationSeparate by generationSeparate by ethnicity, religion, race
71Decrease in Size of Households Privacy and Isolation
72Developmental Stages Emotional Regulation for infants Maternal dyad Repetitive, patterned interaction to hardwire self-regulationExploration of individual self, tentative independence, tolerating manageable separationsIndependence
73Brainstem Peers, Teachers Community Family and Friends Caregiver Blood pressureBody temperatureHeart rateArousal statesDiencephalonMotor regulationAffect regulationHunger/satietySleepLimbicAffiliationAttachmentSexual BehaviorEmotional ReactivityNeocortexAbstract ThoughtConcrete ThoughtPeers, TeachersCommunityFamily and FriendsCaregiverMother
74Rauch Brain scans(It might help to use a laser pointer here also.)This slide depicts a brain and the results of research by a leading neuroscientist named Scott Rauch. He studied the brains of people who had Post Traumatic Stress Disorder. He interviewed them after they had experienced trauma. What he found from this brain imaging study is that when trauma survivors are remembering their trauma, the amygdala was activated.Dr. Rauch also discovered that the Broca’s area of the brain, which is responsible for speech, was not activated when they were remembering their trauma. This would explain the term “speechless terror,” when people are unable to speak in times of great stress. So, when we ask people in the midst of crisis and/or traumatic re-enactment, to “tell us about it,” they really are not able to. The area of the brain that is responsible for speech has actually shut down.
75Bottom-Up Responses Triggering Stimulus Prefrontal Cortex Amygdala Frontal lobes shut down or decrease activity to ensure instinctive respondingAmygdalaBecomes “irritable”,Increasingly sensitive to triggersThalamusAbility to perceive new information decreasesTriggeringStimulusWhat happens in the brain when there is an experience of a real or perceived threat?The “fire or threat alarm” of the autonomic nervous system is activated otherwise known as the amygdala, which sounds the alarm for threat activating the survival responses of fight or flight. The frontal lobes shut down in order to ensure the instinctive survival responses of the autonomic nervous system are fully engaged and the ability to perceive new information is minimal to nonexistent. If the environment is chronically traumatizing, as are most childhood traumatic environments, the survival response system will become chronically activated, resulting in long-term effects on the developing brain and body.(Restak, 1988)
76Lateral Ventricles Measures in an 11 Year Old Maltreated Male with Chronic PTSD, Compared with a Healthy, Non-Maltreated Matched ControlThis 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 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 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.(De Bellis et al., 1999)
77Between Stimulus and Response CortexHippocampusSlowerSensory ThalamusAmygdalaSo, 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.Very FastResponseS Stimulus(LeDoux, 1996)
78Between Stimulus and Response SocialEnvironmentalInterventionCortexNeuroregulatoryInterventionPsychotherapyHippocampusSlowerPsychopharmacologySensory ThalamusAmygdalaSo, 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.Very FastIn 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 FranklResponseS Stimulus(LeDoux, 1996)
79Serum CortisolCortisol Response to a Cognitive Stress Challenge in PTSD Related to Childhood AbuseFinding: 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)This finding may be the result of heightened anticipatory anxiety, or a different interpretation of the environment, among patients in the PTSD group. This would be consistent with prior studies of exaggerated startle response to the threat of the experimental context of a testing environment in PTSD (Morgan et al., 1995). It is also consistent with clinical observations that PTSD patients appear to have an inability to dampen responses to cues that do not represent true threat, an effect that may be related to dysfunctional neural circuitry involving medial prefrontal cortex, amygdala, or other brain regions (Bremner et al., 1999a,b).
80Implications for Children EXPERIENCE CAN CHANGE THE MATURE BRAIN - BUT EXPERIENCE DURING THE CRITICAL PERIODS OF EARLY CHILDHOOD ORGANIZES BRAIN SYSTEMS!From Bruce Perry, Trauma and Brain Development
81St. Aemilian-Lakeside Trauma-Informed Care Video about a trauma-informed program for children with emotional and behavioral problemsSt. Aemilian-Lakeside Trauma-Informed CareWhat may seem like inappropriate or unexpected behaviors in children are usually rooted in their experiences. These are two examples often shared by another NCTIC trainer:Read this example and follow with discussion: “Quiet? Isn’t that the goal and dream of every school? For some of our students, it may signal danger or make them highly anxious. I had a habitually disruptive student explain to me that when it is quiet, it makes him feel like something bad is going to happen or that something is wrong because that is what happens at home when his Dad has been drinking. Another student, who is constantly in trouble for tapping and singing, shared that he cannot recall a time when the radio and tv have not been on in his house. Many of our students are conditioned to expect noise; when this is removed it doesn’t feel right.”Read this example and follow with discussion: “In my experience, a very common reminder is the “Your Mama” joke. It starts off innocently, but it usually doesn’t end well. We tell students it doesn’t matter, ignore it, they don’t even know your Mom. But what we sometimes forget is that jokes and comments about family members strike a nerve in all of us…and it can be devastating for students who have complicated family relationships. One student explained, “I feel like I have to defend my Mom. When my stepdad hit her I didn’t do anything and now I am grown I’m not going to let anyone disrespect her.”Trauma-informed approaches take into account how an individual's past experiences can affect his reactions and perceptions now.Video available at https://www.youtube.com/watch?v=p_dZAqP_tfY.
82A trauma-informed program, organization, or system: The Four R’sA trauma-informed program, organization, or system:RealizesRealizes widespread impact of trauma and understands potential paths for recoveryRecognizesRecognizes signs and symptoms of trauma in clients, families, staff, and others involved with the systemRespondsResponds by fully integrating knowledge about trauma into policies, procedures, and practicesResistsSeeks to actively Resist re-traumatization.Trauma-informed approaches reflect a fundamental shift in the culture of an entire organization.The four R’s highlight basic aspects of culture change that an organization will demonstrate as it becomes trauma-informed.The Four R’s reflect that it is not enough to simply know about trauma.To be trauma-informed, people must be able to identify trauma when they see it, and they must know how to respond in a way that doesn’t unintentionally re-traumatize people.Trauma-Informed approaches can be implemented anywhere, by anyone. Everyone in the organization has a role to play in becoming trauma-informed.
83Gender Differences in PTSD Raul AlmazarAlmazar Consulting
84Olff, Langeland et al Gender Differences in PTSD 2007, Psychological Bulletin
85MaleFemaleRate of Exposure60.7%51.2%Rate of Developing PTSD8.1%20.4%Types of TraumaMore susceptible to negative effects of childhood neglectGreater exposure to traumas that have high rates of PTSDMore than 1/3 of women experienced intimate partner violence within the past 12 monthsMore susceptible to negative effects of sexual abuseMore exposure at a younger agePrior TraumatizationNo difference
86Male Female Cognitive Appraisal Higher levels of perceived control Lower reliance on blaming othersMore likely to report threat and loss appraisalsMore likely to appraise events as stressfulHigher perceived distress loss of personal control and lack of available coping strategiesPick up on threat signals more readily
87MaleFemaleCopingInstrumental MasteryFight or FlightTend and BefriendFreezingPassive avoidancePerry’s theoryPsychological and Biological ResponseAre more sensitized to physiological heyperarousal systems – conduct disorder, ADD, antisocial- Higher SNS activityMore sensitized to dissociated systems – anxiety, physical complaints, withdrawalHPA dysregulation- Oxytocin- EstrogenEndogenous Opioids
88MaleFemaleHealth OutcomesMore aggressive behaviorsHigher PTSD ratesMore anxiety, depressive disorders, somatization, alcohol and drug use
89How Our Bodies Respond to a Real or Perceived Threat or a Trigger Hypothalamus-Pituitary-Adrenal Axis (HPA) Brings body into balanceSympathetic Nervous SystemFight, Flight or FreezeHeart rateSweat responseEnergy increase
90Our Body’s Chemical Response CortisolRegulation of the AdrenalinesIncrease of energyAdrenalinesFight or flightSharpens our focus and stimulates memoryIncreases blood pressure and heart rateShunts blood away from systems that are not needed in danger response to the brain and muscles
91Our Body’s Chemical Response 2 Our natural OpioidsPrevents experiencing the painprevents memory consolidationOxytocinInhibits memory consolidationVasopressinPrevents dehydration
92Biochemical changes during and after the traumatic event Adrenaline - levels are chronically increased resulting in constant hyperstress and inability to distinguish danger signalsInability to sleep, flashbacks, trouble with concentratingShuts off the brain
93Biochemical 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 memoryWhile high, cortisol, thins stomach lining and bones, impairs the immune system, decreases blood flow to the intestines.
94Gender Differences in the Trauma Response Females - tend to dissociate and paradoxically, trauma bondMales - fight or flee, exert power and controlHowever - Both sexes will experience power and control and difficulties with species preservative behavior if the traumas and/or triggers continue too long
95Gender Differences in Trauma Response 2 Females - Tend and BefriendShelley Taylor, UCLAThe role of our hormonesEstrogen amplified the effects of oxytocinAndrogens diminish the effects of oxytocin
96Creating Positive Cultures Trauma Informed Workforce DevelopmentRaul Almazar, RN, MASenior ConsultantSAMHSA’s National Center for Trauma Informed Care
97Some Stressors: Fiscal and funding cuts Downsizing/organizational changes/ mergersDIfferent payor systemsRegulatory changesRole changesReimbursement changesDo more with lessPractice changesNew metricsNatural organizational eventsalmazarconsulting.com
98Impact on the Individual Loss of meaning and purposeDecreased creativityInability to innovateAbsenteeismRetreating into the familiarDistracted, unfocusedPhysical health effectsalmazarconsulting.com
99Organizational Impact TurnoverWorkers CompensationLoss of market advantageDecreased productivityCreation of additional positions to supplement lagging productivityIncreased training costsWith an unhappy workforce - more susceptible to litigationSustained stress response imbedded in the organizational culturealmazarconsulting.com
1002009 GALLUP POLL Employee Engagement Index 33% - Engaged in their jobs 49% - Are not Engaged18% - Actively Disengagedalmazarconsulting.com
101BiologicalTrauma lives in the body. The body has ways to indicate to us that a threat cue is perceived.
102Stress/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 levelsChronic hyperarousal – nervous system does an amazing job of preparing the individual to deal with the stress but:almazarconsulting.com
103Growth, reproduction and immune system all go on hold Leads to sexual dysfunctionIncreases chances of getting sickOften manifests as skin ailmentsIncreases permeability of the blood brain barrierDr. Robert Sapolsky: “Why Zebras Don’t Get Ulcers” – study on salmon
104More on changes as the result of too much stress Chronically high cortisol levelsInsulin resistance, poor sleep patterns – reinforces bad eating habits – no energy to exerciseCan produce cytokines, a protein that promotes inflammation – linked to heart disease, depression, arthritis and fibromyalgiaImpacts regulation adrenalines – implications for hippocampus and addiction
105SAMHSA’s Six Key Principles of a Trauma-Informed Approach SafetyTrustworthiness and TransparencyPeer SupportCollaboration and MutualityEmpowerment, Voice, and ChoiceCultural, Historical, and Gender IssuesWe will discuss each principle in detail.
106Principle 1: SafetyThroughout the organization, staff and the people they serve, whether children or adults, feel physically and psychologically safe.Video: Leah HarrisInstructor Guidance: Show video on Safety featuring Leah Harris (http://youtu.be/ffoOVThHEBQ) and discuss.Safety throughout the organization, staff and people servedPhysical and psychological safetyPhysical setting is safeInterpersonal interactions promote a sense of safety
107For people who use services: Who Defines Safety?For people who use services:“Safety” generally means maximizing control over their own livesFor providers:“Safety” generally means maximizing control over the service environment and minimizing riskMany of these principles—like safety—sound so simple and obvious that you might wonder why it needs to be highlighted. Of course we want everyone to be safe!Safety means that throughout the organization staff and the people they serve:Feel physically safeFeel psychologically safeHave interpersonal interactions that promote a sense of safetyBut if we go below the surface, a more complicated reality emerges.About 10 years ago, Laura Prescott, a trauma survivor and advocate, went on the wards of a psychiatric hospital and asked both patients and staff what it was that made them feel safe.What she found was very interesting. Point for point, staff and patients defined safety in almost completely opposite terms.In fact, it turned out that the very things that staff were doing to make the ward safer were making the patients feel less safe.So what can you do in a situation like this? First, just recognizing that safety may look different depending on your role and situation—or your personal history—is an important first step. The best thing you can do is to ask each individual what makes them feel safe and unsafe.This may mean rethinking policies and practices to attend to what both survivors and staff mean by safety. For example, re-thinking use of seclusion and restraint, use of locked and unlocked spaces, tone of interactions.
108Principles of TIC: SAFETY Raul Almazar, RN, MASAMHSA National Center for Trauma Informed CareNational Association of State Mental Health Program DirectorsContact info:
109Safety Feel psychologically safe Physical setting is safe Throughout the organization: Staff and the people they serve (children and adults)Feel physically safeFeel psychologically safePhysical setting is safeInterpersonal interactions promote a sense ofsafetySafety as defined by the people servedalmazarconsulting.com
110Four Types of Safety Adapted from Sandra Bloom’s Sanctuary Model: Physical SafetyPsychological SafetyMoral SafetySocial Safetyalmazarconsulting.com
111Physical Safety Sense of being safe, living in a physically safe space Physical/Biological SafetyGood health practicesOccupational security and sound financial management (Core TIA Principle: Trustworthiness and Transparency)
112Psychological Safety Sense of mastery over one’s life Living in a world that has some predictabilityAbility to express ones’ creativitySelf-efficacyPresence of structure and organization within which one can try new ideasAbility to make sense of what has happened/is happening
113Moral 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 justiceProviding and receiving the most effective treatmentAttending to power differentials to promote health and healing (Core TIA Principle: Collaboration and MutualityPracticing democratic principles
114Social Safety Sense of feeling secure, cared for, trusted Ability to express oneselfAbility to be safe with other peopleAcceptance of differences and diversity ( Core TIA Principle: Cultural/Historical/Gender sensitivity)
115Psychosocial 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)almazarconsulting.com
116ORGANIZATIONAL Climate vs. Culture Organizational Climate – shared perceptions of policies,practices and procedures present within an organization.(Reichers & Schneider, 1990)Observable manifestations of the organizationOrganizational Culture - underlying core values of anorganization that are inherent, rather than observable.( Bochner, 2003)almazarconsulting.com
117Security vs. SafetySecurity 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.”almazarconsulting.com
118To 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 Generalistalmazarconsulting.com
119Risk ManagementRisk 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)almazarconsulting.com
120Establishing 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.almazarconsulting.com
121External ContextAn 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.almazarconsulting.com
122Internal ContextAn 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.almazarconsulting.com
123Managing 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 riskAccepting or increasing the risk in order to pursue an opportunityRemoving the risk sourceChanging the likelihoodChanging the consequencesSharing the risk with another party or parties (including contracts and risk ﬁnancing)Retaining the risk by informed decisionalmazarconsulting.com
124Examples Failure Mode Effects Analysis (FMEA) Suicide Accidental Death Personal Safety DeviceStrategic Planalmazarconsulting.com
126Principles of TIC: Peer Perspectives on Safety Malcolm Aquinas, MATSAMHSA National Center for Trauma Informed CareNational Association of State Mental Health Program DirectorsContact 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
128SafetyGeneralize safety concerns from the Peer Perspective across two broad areasResponsivenessApplies to behavioral health services and systemsCompetenceApplies to providers of services within those systems
130Environment Allow us to choose our own seat Provide easy access to exitsCommunicate clearly and supportively that we have free egress from roomsExpress empathetic support without strong emotionsRemember that our senses (sight, sound, smell, taste, and touch) are vigilantly searching for possible threats
131Meetings 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?
132Predictability Who interacts with us? How do they present themselves? What schedules exist?How confidently can we move around in our environment?
133Reliability 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?
134Dependability Is there someone we can go to for support? Are they available when we need them?Are they trustworthy?
135Transparency 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?
136Je ne sais quoi Openness – Be inviting and welcoming Honesty – Speak truthfullyCompassion – Demonstrate active kindnessEmpathy – Validate personallyGenuineness – Be presentTransparency – Pull back the curtainVulnerability – Show that this matters
137“You’ve seen my descent. Now watch my rising.”~RumiAlways Remember:It’s what happened to us, not what’s wrong with us; andWe may be stuck, but we are not broken.
138Reducing Risk, Creating Safety Together Leah Harris, MASAMHSA National Center for Trauma Informed CareNational Association of State Mental Health Program DirectorsContact info:
139Redefining RiskIssues 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.
140Responses 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 handcuffsBeing punished with loss of privileges for self-harming on the wardThreatened with interventions I didn’t wantNo one asked “what happened to you?”Consequently, I learned to hide my suicidal thoughts and feelings and self-harming behaviors.
141Safety 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.”
142Liability Drives the System “If we don’t rethink the notion of risk, the liability issue will continue to drive what we do.” - Shery Mead
143Safety Contracts: Not Safe Safety contracts are usually developed to address the provider or support person’s fear and agency fears of liabilitySafety 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 MeadSigning a no-suicide contract should not be used in a coercive way, or as a condition for the person to keep receiving support.
144Ways 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 saidwould be helpful
145AuthenticityTraditional 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.”
146AuthenticityThough 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 indistress/crisis.
147Emotional 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.
148Emotional 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?
149It’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 MeadLearning 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.
150ResourcesDefining Outcomes for Crisis Response by Shery Mead and Eric Kuno:Crisis and Connection by Shery Mead and David HiltonPeer Support: What Makes it Unique? by Shery Mead and Cheryl MacNeil:Intentional Peer Support:Emotional CPR:
151Discussion What changes could be made to address safety concerns? 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?Safety is a surprisingly volatile issue for staff as well as people served.Often, physical safety is a concern, especially for people who work at night and have to walk into dark parking lots or who work in rough neighborhoods.Incidents of workplace violence can have a ripple effect far beyond the specific circumstances.Staff may fear that their jobs are in jeopardy due to budget cutbacks, or they may be terrorized by workplace bullying.While these issues cannot be resolved in this workshop, getting people to identify their safety concerns is an important first step.
152Principle 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 RisserInstructor Guidance: Show video on Trustworthiness and Transparency featuring Pat Risser (http://youtu.be/gtMTBnGNvoM) and discuss.Maximizing trustworthiness, making tasks clear, and maintaining appropriate boundariesOrganizational operations and decisions are conducted with transparencyConstantly building trust
153Examples of Trustworthiness Making sure people really understand their optionsBeing authenticDirectly addressing limits to confidentialityOne of the most powerful ways of building trust is to give people full and accurate information. Just telling people what’s going on and what’s likely to happen next can be very important.Being clear is essential. Telling people they have more control than they really do will eventually destroy trust. For example, calling a program “peer-run” when in fact key decisions are made by the host organization is not trustworthy. Much better to explain what decisions are made by peers and what decisions are not.Similarly, if you are required by your organization to break confidentiality when someone talks about wanting to hurt themselves, better to tell the individual up front than to assure them of confidentiality and then break that trust.Sharing your own reactions and responses in a truthful manner—being authentic—is also essential. Trauma survivors often have finely tuned “radar” to detect other people’s emotional states—they have had to develop this capacity, a form of vigilance, to protect themselves. If you are untruthful about your feelings—even if you are trying to protect the other person—they are likely to detect it, and trust goes out the window.
154Discussion 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?
155Principle 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 SpencerIn this context, the term “peer” refers to individuals with lived experiences of trauma.In the case of children this may also refer to family members of children who have experienced traumatic events and are key caregivers in their recovery.Instructor Guidance: Show video on Peer Support featuring Cicely Spencer (http://youtu.be/qCWAY4lssTs) and discuss.
156Examples of Peer Support Peer support = A flexible approach to building mutual, healing relationships among equals, based on core values and principles:VoluntaryNon-judgmentalRespectfulReciprocalEmpatheticPeer support is not a “service model”—it is about developing authentic mutual relationships, not applying a cookie-cutter approach to everyone.Peer supporters don’t use clinical language or focus on what’s “wrong” with people.Peer support doesn’t offer top-down “helping” that disempowers people by taking away choice and voicePeer support is not “Peer Counseling”, which implies that one person knows more than the other—peer support is about power-sharingThe heart of peer support involves building trust. That isn’t possible if people feel that peer support staff are acting as proxies for clinicians, case managers, or administrators, or are reporting on people’s behavior.Trauma-informed peer support is not just important for people who receive services. It is important that staff who are trauma survivors have access to peer support, too.
157Does your organization offer peer support for staff? DiscussionDoes 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?
158Principle 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.Maximizing collaboration and sharing of power with consumers and familiesLeveling of power differences between staff and clients and among organizational staff from direct care staff to administratorsRecognition that healing happens in relationships and meaningful sharing of power and decision-makingEveryone has a role to play in trauma-informed approaches; “one does not have to be a therapist to be therapeutic.”
159Examples of Collaboration “There are no static roles of ‘helper’ and ‘helpee’—reciprocity is the key to building natural community connections.”—Shery MeadHospital abolished special parking privileges and opened the “Doctor’s Only” lounge to othersModels of self-directed recovery where professionals facilitate but do not directDirect care staff and residents in a forensic facility are involved in every task force and committee and are recognized for their valuable inputCollaboration and mutuality refers both to collaboration between staff and people served and among different levels of staff.
160DiscussionCan 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?
161Principle 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-empowermentVideo: GAINS Center Interview VideoVideo: William KellibrewStrengthens clients and family member’s experience of choiceRecognizes that every person’s experience is uniqueIndividualized approachInstructor Guidance: Show video on Empowerment, Voice, and Choice featuring William Kellibrew (http://youtu.be/YinAbgpJxCE) and discuss.GAINS Center Video available at
162Examples Asking at intake: “What do you bring to the community?” Treatment activities designed and led by hospital residentsMurals on walls painted by staff and residentsTurning “problems” into strengthsThere are as many ways of building on people’s strengths and resilience as there are people on the planet. What are some ways you can use your clients’ strengths?Sometimes people want a list of things they should be doing, but this principle reflects a positive, creative attitude rather than a specific technique.Empowerment, voice and choice apply to staff as well as the people served. We often see patient art on the walls of psychiatric facilities. In one hospital, staff with artistic talents joined residents in painting murals on the walls—a great example of collaboration as well as building on strengths.Some examples of turning “problems” into strengths:In one hospital, a young woman who was often self-injurious when she was under stress, was made the hospital safety officer. Whenever she started to want to hurt herself, she made rounds and identified all the possible ways she could do it and let staff know. She often found dangerous items in the environment that no one else had noticed.In another hospital, a person who was extremely meticulous, always keeping detailed notes about everything that happened. After a TIC training, staff stopped trying to get him to give up his stacks of paper and made him a peer advocate. His detailed note-taking became a valued asset when advocating for others.
163Discussion Question How can you use your clients’ strengths? Example: In one adolescent residential program, a young man was required to make amends to the community after he was involved in an incident. While this process is important in establishing a sense of responsibility, it has the potential to be humiliating, especially for trauma survivors who often have a deeply embedded sense of shame and self-blame. In this case, staff knew that the boy was musically talented, and they encouraged him to write a rap song and sing his apology. His fellow residents loved it, he was able to feel good about himself at the same time he was taking responsibility for his actions, and the number of incidents he was involved with dropped dramatically.
164DiscussionCan 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?
165Principle 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 CampbellInstructor Guidance: Show video on Cultural, Historical, and Gender issues featuring Iden Campbell (http://youtu.be/trezdakbncw) and discuss.Organization actively moves past cultural stereotypes and biasesOffers gender responsive servicesLeverages the healing value of traditional cultural connectionsRecognizes and addresses historical trauma
166Examples: 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 PattersonA women’s prison in Hawaii reinvented itself as a place of healing for the women it serves.Video available at
167Traumatic Reminders Loss of Control Power Differential Lack of Predictabilityalmazarconsulting.com
168I'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
169SAMHSA’s National Center for Trauma Informed Care SAMHSA’s National Center for Trauma Informed CareAlmazar Consulting