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Trauma Informed System of Care: Changing Our Perspective

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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/circumstances cause trauma.
The Three E’s in Trauma 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 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.

5 Traumatic 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

6 Effect of Trauma The 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.


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

13 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) 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

15 Therefore ... 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

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

17 Avoidance 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

18 Trauma Sensitive Person Served Trauma Assessment And Treatment
Almazar Consulting

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

20 Trauma Informed System
Resiliency Recovery Trauma Informed System Trauma Informed Care Trauma Sensitive Non- Controlling Non- Coercive Person Served Trauma Assessment and TX Universal Precautions Collaboration Partnerships Healing Hope 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 The higher the ACE Score, the greater the likelihood of :
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 I 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.

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. 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 audience 1 in 16 were exposed to 4 categories 22% 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

29 The ACE Comprehensive Chart
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 Adults 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

32 Childhood 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. 3 2 1 Almazar Consulting

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

34 ACE 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 2005 Abuse 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 1999 Ever Hallucinated* (%) ACE Score *Adjusted for age, sex, race, and education. Almazar Consulting

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

36 Health Risk Behaviors Almazar Consulting
Developed in response to neurological impacts and pain of childhood adverse experiences. Almazar Consulting

37 Adverse 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 predisposition A person with 4 categories of adverse childhood experiences is 260% more likely to have Chronic Obstructive Pulmonary Disease (COPD) . Almazar Consulting

38 Childhood Experiences and Adult Alcoholism
4+ 3 A 500% increase in adult alcoholism is directly related to adverse childhood experiences. 2/3rds of all alcoholism can be attributed to adverse childhood experiences This 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. 2 1 Almazar Consulting

39 ACE 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 life 78% of drug injection by women can be attributed to ACEs Keep in mind Relationships of this magnitude are rare in Epidemiology. N = 8, 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 Significant implications for medical practice and treatment programs
Basic cause of addiction is experience-dependent, not substance-dependent Significant implications for medical practice and treatment programs ACE 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

43 Serious Social Problems
Almazar Consulting

44 Childhood Experiences Underlie Rape
4+ 3 2 Repetition 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. 1 Almazar Consulting

45 ACEs 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 violence Women 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.

46 The 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

47 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 women and men. Almazar Consulting

48 Adverse 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

49 ACE Score and Unintended Pregnancy or Elective Abortion
Higher ACE score leads to increased unintended pregnancy (red) or Elective Abortion (yellow) Almazar Consulting

50 Adverse 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

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

52 Pink =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 Pregnancy Pink =self Green =mother Percent who had a teen pregnancy This 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 Very Twice often Almazar Consulting

53 ACE 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 Problems Almazar Consulting

54 “What’s wrong with you?”
“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 Trauma 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 agitation Disrupted ability to see the world as a safe place looks like paranoia Distrust of others can be interpreted as paranoia (even when based on experience) Disruptions in organized thinking for decision-making appears as psychosis

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 Attachment & Belonging Community, Culture, Spirituality
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 Community, 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. Wholeness Growth

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). ( 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.

65 Punishment vs. Compassion
Killarney Secondary School – 2013 Vandalism, false fire alarms, locker break-ins drug deals common Lincoln High School – 2011 Kids kicked out of other schools, last chance; gangs controlled building. 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% Punishment vs. Compassion Killarney Secondary School 2010 – 2013 Vandalism, false fire alarms, locker break-ins drug deals common 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 bad – willful disobedience Students feel like potential criminals What’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 – 2011 Kids kicked out of other schools, last chance; emotional, physical, sexual abuse; gangs controlled building, 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 respected and treated fairly What is happening with this kid? Suspensions and absenteeism down 87%

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

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

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 Peers, Teachers Community Family and Friends Caregiver
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 Peers, Teachers Community Family and Friends Caregiver Mother

74 Rauch 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.

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

76 Lateral Ventricles Measures in an 11 Year Old Maltreated Male with Chronic PTSD, Compared with a Healthy, Non-Maltreated Matched Control This slide demonstrates the physical impact of trauma on the brain. This work comes from an important study by Dr. Michael DeBellis (pronounced: Bayless with a long ‘a’) and his colleagues that was published in Biological Psychiatry in 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)

77 Between Stimulus and Response
Cortex Hippocampus Slower Sensory Thalamus Amygdala So, let’s say for example, all of a sudden the door in the back of this auditorium slams shut. What do you do? You jump. Maybe; you get sweaty for a minute, you might begin to slightly move your body as if you were going to get up and run out. That is your amygdala reacting to the sound stimulus. But immediately afterwards, your cortex and your hippocampus translate the stimulus and you say, “Wait a minute; I’m sitting in this room; I haven’t been hurt by sitting in an auditorium and a door slamming.” So, you relax and get back to the training. Your response is to relax again. Very Fast Response S Stimulus (LeDoux, 1996)

78 Between Stimulus and Response
Social Environmental Intervention Cortex Neuroregulatory Intervention Psychotherapy Hippocampus Slower Psychopharmacology Sensory Thalamus Amygdala So, to help the traumatized people we serve, we need to build in structures to help them regulate their emotions and behavior. One way, is to create neuroregulatory interventions. Some researchers believe that the common pathway of many of the agents that we use is to diminish the amygdala from responding. We can also help trauma survivors by creating social environmental interventions, and cognitive behavioral and social skill approaches. We can survey the environment to reduce factors that may contribute to distress and also work to enhance emotional processing interventions. We need to create environments where behavior is anticipated and not reacted to. Very Fast 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 Response S Stimulus (LeDoux, 1996)

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) 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).

80 Implications for Children

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

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

83 Gender Differences in PTSD
Raul Almazar Almazar Consulting

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

85 Male Female Rate of Exposure 60.7% 51.2% Rate of Developing PTSD 8.1% 20.4% Types of Trauma More 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 Traumatization No difference

86 Male Female 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 Male Female 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 Male Female Health Outcomes More 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 Employee Engagement Index 33% - Engaged in their jobs
49% - Are not Engaged 18% - Actively Disengaged

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

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
Safety Trustworthiness and Transparency Peer Support Collaboration and Mutuality Empowerment, Voice, and Choice Cultural, Historical, and Gender Issues We will discuss each principle in detail.

106 Principle 1: Safety Throughout the organization, staff and the people they serve, whether children or adults, feel physically and psychologically safe. Video: Leah Harris Instructor Guidance: Show video on Safety featuring Leah Harris ( and discuss. Safety throughout the organization, staff and people served Physical and psychological safety Physical setting is safe Interpersonal interactions promote a sense of safety

107 For people who use services:
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 Many 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 safe Feel psychologically safe Have interpersonal interactions that promote a sense of safety But 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.

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 Feel psychologically safe Physical setting is safe
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
Environment Meetings Predictability Reliability Dependability 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: It’s what happened to us, not what’s wrong with us; and 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 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.

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 Risser Instructor Guidance: Show video on Trustworthiness and Transparency featuring Pat Risser ( and discuss. Maximizing trustworthiness, making tasks clear, and maintaining appropriate boundaries Organizational operations and decisions are conducted with transparency Constantly building trust

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

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?

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 Spencer In 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 ( and discuss.

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 Respectful Reciprocal Empathetic Peer 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 voice Peer support is not “Peer Counseling”, which implies that one person knows more than the other—peer support is about power-sharing The 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.

157 Does your organization offer peer support for staff?
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?

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. Maximizing collaboration and sharing of power with consumers and families Leveling of power differences between staff and clients and among organizational staff from direct care staff to administrators Recognition that healing happens in relationships and meaningful sharing of power and decision-making Everyone has a role to play in trauma-informed approaches; “one does not have to be a therapist to be therapeutic.”

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 Collaboration and mutuality refers both to collaboration between staff and people served and among different levels of staff.

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?

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 Video Video: William Kellibrew Strengthens clients and family member’s experience of choice Recognizes that every person’s experience is unique Individualized approach Instructor Guidance: Show video on Empowerment, Voice, and Choice featuring William Kellibrew ( and discuss. GAINS Center Video available at

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 There 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.

163 Discussion 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.

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?

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 Campbell Instructor Guidance: Show video on Cultural, Historical, and Gender issues featuring Iden Campbell ( and discuss. Organization actively moves past cultural stereotypes and biases Offers gender responsive services Leverages the healing value of traditional cultural connections Recognizes and addresses historical trauma

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 Patterson A women’s prison in Hawaii reinvented itself as a place of healing for the women it serves. Video available at

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

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