Presentation on theme: "Assessing for and Addressing Trauma in Recovery-Oriented Practice"— Presentation transcript:
1Assessing for and Addressing Trauma in Recovery-Oriented Practice Paula G. Panzer, M.D.Eric Arauz, MLERKevin Ann HuckshornRN, MSN, CADCAssessing for and Addressing Trauma in Recovery-Oriented PracticeImplementing Recovery-Oriented Practices
2Assessing for and Addressing Trauma in Recovery-Oriented Practice January 25, 2012Kevin Ann Huckshorn, RN, MSN, CADCDelaware Director for the Division of Substance Abuse and Mental HealthPaula Panzer, M.D.Director of Training and Professional DevelopmentJewish Board of Family and Children's ServicesEric Arauz, MLERArauz Inspirational EnterprisesAdjunct Instructor, Department of Psychiatry, Robert Wood Johnson Medical SchoolNew Jersey Governor’s Council on Alcoholism and Drug AbuseAPNA RTP Steering and Curriculum CommitteesModerated byLarry Davidson, Ph.D.Project Director, Recovery to Practice (RTP)Development Services Group (DSG), Inc.
3Assessing for and Addressing Trauma in Recovery-Oriented Practice If you are not hearing the audio…To access the audio portion of this Webinar, please dial the conference service directly and enter the participant access code:Audio Conferencing (toll-free):Participant Access Code:
4Assessing for and Addressing Trauma in Recovery-Oriented Practice 3–3:05 p.m.3:05–3:10 p.m.3:10–3:25 p.m.3:25–3:40 p.m.3:40–3:55 p.m.3:55–4:30 p.m.WelcomeIntroductions & OverviewTrauma-Informed Care: A Shift in Thinking for Service ProvidersUnderstanding and Addressing the Impact of Trauma in a Recovery-Oriented Practice The Trauma of DelusionsDiscussionWilma Townsend SAMHSA/CMHSLarry Davidson, Ph.D. DSG, Inc.Kevin Ann Huckshorn RN, MSN, CADCPaula Panzer, M.D.Eric Arauz, MLERParticipants & Presenters
5Assessing for and Addressing Trauma in Recovery-Oriented Practice Process for Questions, Answers, and Downloading SlidesOur speakers will present their slides, which will be followed by moderated questions and answers. We encourage you to ask questions or make comments! To ask a question, click on the Q/A tab and type your question in the window that opens, or press *1 for the operator, who will take your question in the order in which it is received.This Webinar will be recorded and archived for future use. Please visit for more information.
6Trauma-Informed Care: A Shift in Thinking for Service Providers Kevin Ann HuckshornTrauma-Informed Care: A Shift in Thinking for Service ProvidersKevin Ann Huckshorn, RN, MSN, CADC DSAMH State Division Director Substance Abuse and Mental Health
7Outline What is trauma? What is Trauma-Informed Care (TIC)? What are the differences between a trauma-informed and uninformed service system?Trauma assessment
8What Makes an Event Traumatic? Traumatic Events AreSudden, unexpected, and extreme.Usually involve physical harm or perceived life threat. (Research has shown perception of “life threats” is a powerful predictor of the impact of trauma.)People experience these events as out of their control.Certain stages of life make people more vulnerable to the effects of trauma, including childhood, teenage years, and early 20s. All presuppose a greater impact on life in adulthood.(Tedeschi, 2011)
9Traumatic Life Events That Can Result in Mental Health Problems Are interpersonal in nature: intentional, prolonged, repeatedIncludes sexual abuse, physical abuse, severe neglect, emotional abuseIncludes witnessing violence, repeated abandonment, sudden and traumatic lossCan occur in childhood, adolescence, or at any point in an adult’s lifetime depending on extent (Terr, 1991; Giller, 1999; Felitti, 1998)The process of “becoming homeless” is widely believed to have exposed all involved to trauma; homelessness itself is traumatic(Hopper, Bassuk, & Olivet, 2010)
10The Definition of Trauma-Informed Care “Trauma-Informed Care is a strengths-based framework thatIs grounded in an understanding of (and on) responsiveness to the impact of traumaEmphasizes physical, psychological, and emotional safety for both providers and survivorsCreates opportunities for survivors to rebuild a sense of control and empowerment.”Care that is stabilizing and addresses physiologic dysregulation(Hopper, Bassuk, & Olivet, 2010)
11How Many People Have Experienced Trauma? What about the people we serve?What about people in other care settings?What is some of the research regarding the prevalence of trauma?
12Prevalence of Trauma Mental Health Population: Adults 97% of homeless women with serious mental illness (SMI)experienced severe physical and sexual abuse87% experienced abuse in both childhood and adulthood (Goodman et al., 1997)90% of public mental health clients havebeen exposed to traumahad multiple experiences of trauma (Mueser et al., in press; Mueser et al., 1998)81% of adults diagnosed with bipolar disorder or Dissociative Identity Disorder (90%) were sexually or physically abused as children (Herman et al., 1989; Ross et al., 1990)29–43% of people with SMI have posttraumatic stress disorder (PTSD) (CMHS/HRANE, 1995; Jennings & Ralph, 1997)Image: Photo ofhomeless womanIt tells us that trauma is widespreadRosenberg and his colleagues from Dartmouth University who have done a good deal of research on people in the public mental health system found that 90% of these individuals have been exposed to traumaGoodman, in a separate study, found that 51-98% were exposed.Meuser and Felitti identified that most have had multiple experiences of various types of traumatic stressHomeless women are particularly vulnerable to rape
13Prevalence of Trauma Mental Health Population: Children & Adolescents Canadian study of 187 adolescentsreported 42% had PTSD.(Kotlek, Wilkes, & Atkinson, 1998)In a U.S. study of 100 adolescent inpatients, 93% had histories of trauma and 32% had PTSD. (Lipschitz et al., 1999)A study of one State system’s child/adolescent long- term care service users (162) found 100% had documented histories of trauma. (Massachusetts DMH, 2007)Image: Photo of young girlIn terms of the prevalence of Post Traumatic Stress Disorder, the best defined and most clearly understood trauma diagnosis, among people with serious mental illness –
14Prevalence of Trauma: Substance Abuse Population Up to 2/3 of men and women in SA treatment report childhood abuse and neglect. (CSAT, SAMHSA, 2000)Study of male veterans in SA inpatient unit77% exposed to severe childhood trauma.58% history of lifetime PTSD. (Triffleman et al., 1995)50% of women in SA treatment have history of rape or incest. (Gov. Comm. on Sexual and Domestic Violence, Comm. of Mass., 2006)Image: Photo of drug-injecting manRosenberg and his colleagues from Dartmouth University who have done a good deal of research on people in the public mental health system found that 90% of these individuals have been exposed to traumaGoodman, in a separate study, found that 51-98% were exposed.Meuser and Felitti identified that most have had multiple experiences of various types of traumatic stressHomeless women are particularly vulnerable to rape
15Prevalence of Trauma: Incarcerated Women Framingham Women’s Prison, Mass.90% receiving mental health services or SA services have trauma histories. (Governor’s Task Force, Comm. of Mass., 2005)Correctional Institute for Women, R.I.40% – Childhood sexual abuse55% – Childhood physical abuse53% – Adult rape63% – Adult physical assault34% – Lifetime PTSD(Zlotnick, 1997; Zlotnick, Najavits et al., 2003)In terms of the prevalence of Post Traumatic Stress Disorder, the best defined and most clearly understood trauma diagnosis, among people with serious mental illness –Image: Photo of imprisoned women
16Prevalence of Trauma: Incarcerated Youth 93% of males in a juvenile justice (JJ) facility reported trauma history (compared to 84% females), but more females met criteria for PTSD (18% female, 11% male). (Abram et al., 2004)70–92% of incarcerated girls reported sexual, physical, or severe emotional abuse in childhood. (DOC, 1998; Chesney & Sheldon, 1997)PTSD prevalence data varies widely:3–50% in JJ settings and up to eight times higher than community samples of same-age peers. (Arroyo, 2001; Garland et al., 2001; Teplin et al., 2002; Saigh et al., 1999; Saltzman et al., 2001)Image: Photo of imprisoned manIn terms of the prevalence of Post Traumatic Stress Disorder, the best defined and most clearly understood trauma diagnosis, among people with serious mental illness –
17Trauma PrevalenceThe prevalence of trauma appears to be a link or “cross cutting principle” that affects people receiving services in all human service and health care settings.These individuals often experience depression, SA, serious mental conditions, vulnerability to re-victimization, difficulty working, and/or impaired social networks.(Hopper, Bassuk, & Olivet, 2010)
18Pervasiveness of Trauma “In my own case, growing up in an alcoholic home, I came to accept chaos as a normal state of affairs rather than the exception. I wound up sabotaging my first marriage simply because the calm left me unsettled and nervous; I had to create chaos where none existed because that's all I was familiar with.” —Suzanne Somers, actress and authorImage: Photo of Suzanne Somers
19Well Known and Not-So-Well-Known People Aren’t Immune from Trauma Desperate Housewives star Teri Hatcher revealed she was sexually abused by her uncle after he was arrested for molesting another girl.Many well known and not-so-well-known people have experienced trauma.Image: Celebrity photos
20What Does All of This Mean? Great question. A lot of really smart people are working on this answer. What we do know …Most of the people served in …MH/SA treatment settingsDOC or JJ systemsHomeless systems… have trauma histories.Many people served in other care systems have experienced trauma (ID, TBI, elderly).People who are not in care settings may also experience trauma—that means our staff, too.Traumatic exposure is epidemic among adults and children in the mental health system.Many clinicians in the US see PTSD as the only trauma-related diagnosis. Increasingly, we are appreciating that a range of other disorders can be directly related to trauma exposure or individuals might suffer from such co-occurring such as substance abuse, affective illness, personality disorders and psychotic disorders.(Hodas, 2004; Frueh et al., 2005; Mueser et al., 1998; Lipschitz et al., 1999; NASMHPD, 1998)
21Trauma: The interface Between Exposure, Choices, and Health Status Research has focused on the effects of childhood trauma on adult health outcomes:Adverse Childhood Experiences (the ACE study) demonstrated the serious health consequences of trauma.Increasing ACE scores correlated with increasing numbers of risky health behaviors as coping mechanisms in adulthood, includingeating disorders, smoking, substance abuse, self-harm, sexual promiscuity.These behaviors resulted insevere medical conditions such as heart disease, pulmonary disease, liver disease, STDs, GYN cancer, and early death.Risk Behaviors developed as a coping response to trauma – alcohol to manage flashbacks, - can then put the person at greater risk..perpetuating the cycle of trauma(Felitti, Anda et al., 1998)
22OK. So People Who Get Services in Public Health Care Settings Are Most Likely Trauma Survivors. So What?Calls for implementation of a TIC framework within our service settingsJust like in change theory, this is a multistep, staggered process that highlights three key focus areas:Attitudes (of staff and clients)Implementation (how do we make changes?)Outcomes (How do we measure changes? May include quantitative or qualitative measures.)(Hopper, Bassuk & Olivet, 2010)
23Implementing TIC: Outcomes TIC service settings have better outcomes than “services as usual” for many symptoms and social issues and show a decrease in MH and SA symptoms/ improvement in engagement.Trauma-informed services may have an improved and positive effect on housing stability (early research).Trauma-informed services may lead to a decrease in crisis services use and a loss of housing and inpatient care.Trauma-informed services are cost effective.Clients respond better to trauma-informed services.(Hopper et al., 2010)
24Implementing TIC: Starting Points Do an organizational “self-assessment” if you feel the need to explore your agency’s readiness. Or “just do it.”Identify and use a theory-based model as a guide. Document your organization’s beliefs/vision in writing and train staff accordingly.Strive to avoid any practices that may be re-traumatizing in your system.Implement universal trauma screening on admission, using standardized measures.(Hopper et al., 2010)
25What if You Don’t Know if Someone Has a Trauma History? What Do You Do? Staff in human service settings need to take a “universal precautions approach.”Assume that everyone you serve has a history of trauma.(Hodas, 2004)
26Universal Precautions These kinds of “precautions” are aimed at preventing illness or injury before it happens.Like hand-washing techniques to avoid transmitting germs or using condoms for “safe sex.”In a trauma-informed setting, this means using strategies to ensure comfort: always be welcoming, avoid conflict/violence, meet needs assertively, and minimize any traumatic event that could hurt clients or staff.(NETI, 2010)
27What Does All This Mean?For the people we serve, the outcomes of traumatic life experiences primarily mean this:“The loss of ability to regulate the intensity and duration of affect …” (Schore, 2003)“A breakdown in the capacity to regulate internal states including fear, anger, and sexual impulses.” (van der Kolk, 2005)
28The Three Contexts of Healing When Systems Are Trauma Informed Safety:A core developmental need for human beingsThe defining experience of children or adults who have been traumatized is a pervasive mistrust of those “in power,” whether these are parents, caretakers, providers, police, or other officials. These people have suffered core damage to an early developmental stage called “trust vs. mistrust.” To bridge this gap, TIC systems have to first build trust.(Bath, 2008)
29The Three Contexts of Healing When Systems Are Trauma Informed Connections:The second pillar of TIC expects the healthy development of relationships between service recipients and their care providers.These are life-giving relationships that are required to bridge the distrust these victims bring to our systems of care. People who have experienced trauma bring suspicion, avoidance, and hostility to their relationships. It is what they expect. It is our role to change this.(Bath, 2008)
30The Three Contexts of Healing When Systems Are Trauma Informed Emotion and Impulse Management:The most pervasive impact of trauma is the dysregulation of emotions and impulses. The ability to regulate these is also one of the most “fundamental protective factors” for healthy adults.As such, all providers of human services should understand the need to teach self-regulation skills, e.g., how to learn to “self- soothe.” Active listening can help; labeling problem behaviors and their consequences is another step in this process. Practicing new strategies—with supervision—is key.(Bath, 2008)
31What Does a Trauma-Informed Care System Look Like?
32Trauma Informed Non-Trauma Informed How would trauma be recognized?Recognition of high prevalence of traumaLife history is appreciated/recordedRecognition of setting/culture and practices that are re-traumatizingLack of education on trauma prevalence and “universal” precautionsPerson seen without family/social history“Tradition of Toughness” valued as best care approach
33Trauma Informed Non-Trauma Informed How would the service feel?Power/Control is minimized—constant attention to practicesLanguageCounselors, StaffCaregivers/Supporters—CollaborationAddress training needs of staff to improve knowledge, sensitivity, accessibilityStaff demeanor, not being helpful, authoritative tone of voiceTechs, GuardsRule Enforcers—Compliance“Client blaming” as fallback position without trainingOthers know what is best – paternalistic modelSelf-injury – effective as a strategy for flashbacks, terror, numbinghelps survivor regain controlclient who says it makes her feel strong instead of powerlesshurt self instead of otherstrigger or stop dissociationconvert emotional pain to physical painExample about a woman’s experience. Complicated PTSD and Bipolar DO. Laura Prescott discussed the difference between a Trauma Informed vs trauma uninformed systemEnvironment felt unsafe. Large men – loud voices – keys displayed – doors locked. This is a woman who had been locked in her room and repeatedly abused by her father. It is late evening, the time when she was typically abused. A staff member comes into the unit and yells to another staff person. Large man with keys on belt. Individual triggered – re-experience the abuse in her body feels unsafe. To manage - she finds a paper clip and starts digging into her skin. Three men jump on her to restrain her – put in four point restraints. Alternatively, gets triggered due to bedtime (internal trigger) – she starts to pace – the nurses approaches her to talk – she grabs a paperclip and starts to dig into her skin.
34Trauma Informed Non-Trauma Informed How would people be respected?Understand function of behaviors (rage, apathy, irresponsibility, self- injury)Objective, neutral languagePeer staff employees are present to assist other staff in understanding the person’s perspectiveTransparent systems open to outside partiesBehavior seen as intentionally provocative and volitionalLabeling language: manipulative, needy, gamey, “attention seeking”Lack of Peer SupportsClosed system—advocates discouragedOthers know what is best – paternalistic modelSelf-injury – “valiant attempts” (Sandy Bloom) at coping -effective as a strategy for flashbacks, terror, numbinghelps survivor regain controlclient who says it makes her feel strong instead of powerlesshurt self instead of otherstrigger or stop dissociationconvert emotional pain to physical pain(Fallot & Harris, 2002; Cook et al., 2002; Ford, 2003; Frueh et al., 2005; Jennings, 1998; Prescott, 2000)
36Why Is Trauma Assessed?A more sensitive review of someone’s trauma history should be conducted respectfully and shortly after your first contact in order toIdentify past or current trauma, violence, abuse experiencesLearn how trauma is expressed when the person is under duressIncorporate this information into an individualized, person-specific care planHealth care settings need to request this information from referral sources or do a short assessment themselves.(Cook et al., 2002; Fallot & Harris, 2002; Maine BDS, 2000)
37Common Trauma Symptoms People Struggle With DissociationFlashbacksNightmaresHypervigilanceTerrorAnxietyNegative auditory hallucinationsNumbnessDepressionSubstance abuseSelf-injuryEating problemsSexual promiscuityPoor judgment and continued cycle of victimization. People with traumatic exposure may have difficulty functioning within a level of optimal arousal and demonstrate symptoms of hypo or hyper arousal. Hypoarousal being demonstrated as numbing, dissociation, flattened affect, withdrawal, disconnection. Some of the hyperarousal sx demonstrate that continued emergency state of fight or flight include: flashbacks, terror, hypervigilance.(DSM IV-TR, 2000)
38Trauma Assessment Components Typesexual, physical, emotional, neglect, witnessed domestic violence, exposure to disaster, combat exposure, otherAgeWhen the abuse occurred is important in terms of the impact on the person’s developmentWhoWas abuser a stranger? A family member?(At end of entire slide) Someone who had a relatively stable life and was then raped at 22 will have had a before and after life changing event. But this is different from someone sexually abused by a parent consistently from an early age who may suffer from more a severe fragmentation of the self and the inability to become close to or trust another person.(Carmen et al., 1996)
39Trauma Assessment: Key Principles Focus on “what happened to you?” instead of “what is wrong with you?”Begin to develop a therapeutic relationship (trust, respect, caring) during this process.Addresses context of the human experience rather than a pathology framework(Bloom, 2002)
40Trauma Assessment: Key Principles Information from the assessment and “positive responses” should be incorporated into service plans, or the assessment has no value.Also, if previously disclosed, what happened? Ask if the person has ever told anyone, at all …Young child in one of our programs was in a fire and spent entire inpatient stay playing with fire engine- helped in terms of assessment and treatment. At the beginning, dolls died in fire. By end, the firefighters were saving the dolls
41In Summary…Most people who access public services have been traumatized.When stressed, past trauma informs current behaviors.Troubling behaviors can often be learned survival strategies.Try to understand the consumer’s history and how to support efforts to teach self-calming and regaining control.Practices that take away control and choice can be traumatizing.Watch for trauma “uninformed” practices and try to prevent, avoid, or eliminate these.Keep asking—Is what I am doing respectful and trauma informed? Is it how I would like to be treated?
42“If you can, help others; if you cannot do that, at least do not harm them.”—Dalai Lama
44Paula G. PanzerUnderstanding and Addressing the Impact of Trauma in a Recovery-Oriented Practice: Key ConceptsPaula G. Panzer, M.D. Director of Training and Professional Development Jewish Board of Family and Children's ServicesNew York, N.Y.
45Understanding trauma is not just about acquiring knowledge. It’s about changing the way youview the world.—Sandra Bloom, 2007
46Because coping responses to abuse and neglect are varied and complex, trauma survivors may carry any psychiatric diagnosis and frequently trauma survivors carry many diagnoses.Sidran Institute, 2010
47We Create Shared Definitions … … to create a common understanding and languageWe start with those involved in the dialogueConsumersCliniciansCommunity partnersWe define to develop policies and practicesWe check in to make sure the definition is relevant
49Trauma Traumatization Trauma—something that threatens one’s psychic or physical integrityTraumatization occurs when both internal and external resources are inadequate to cope with external threat. (Bessel van der Kolk, 1989)
50Traumatic Stress and Traumatic Stress Disorders Physical and emotional responses of an individual to traumaWhen traumatic events overwhelm an individual’s ability to cope and elicit feelings of terror, powerlessness, rage, and out-of- control physiological arousalDisorders related to and/or specifically a result of trauma exposurePTSDASDDID…DES NOSAnd then some less clearly definedProtect – Promote Safety and TrustworthinessConnect – Focus on RelationshipsRespect – Engage in Choice and CollaborationRedirect (Teach and Reinforce) – Encourage Skill-Building and Competence(Adapted from Hummer, V., Crosland, K., and Dollard, N., 2009)
51Trauma-Specific Services (TSS) Trauma-Specific Services (TSS) are models designed to treat the psychological and behavioral consequences of trauma exposure.Targeted to the period of time relative to trauma exposure (immediate, short-term, and delayed) and to the type of reactions and symptoms being addressed (e.g., supporting adaptive coping after a disaster or treating chronic PTSD).Based upon evidence for effective interventions.TSS should be delivered in a TIC system.TSS are recovery oriented ONLY when offered in a person-centered and empowering manner.
52Trauma-Informed Lens and Assessment Trauma-informed work requires use of an informed lens.Trauma histories and trauma symptoms are not usually spontaneously offered.We must ask.Image: Sunglasses
53Traumatic Stress Responses and Symptoms Activation responsesTrigger responseLevel of activationAvoidance responsesEmotional numbing, dissociation, denial, thought suppressionIntrusive and incomplete remembranceAvoidance of trauma remindersRe-experiencingHyperarousalTrauma-related, sexualized, aggressive, or oppositional behaviorsDissociationUnsafe behaviors
54AVOIDANCEMany consumers won’t initiate discussion about trauma exposure because theymay fear talking about the trauma will trigger them and cause an intense and painful reactionmay feel embarrassed, guilty, responsible for, or stigmatized by experiencestrauma memories are typically fragmented and confusingsome have been rejected or further injured with prior attempts to tellpast experiences with telling have been too painfulabusers threatened retaliation if the secret was revealedMany clinicians are reluctant to initiate discussion about trauma exposurestudies show clinicians underestimate the incidence of consumer trauma exposure and fail to askfear it will be too distressing for their consumersfear the effect it will have on them, or feel they don’t have the skills to help the consumer after disclosureundervalue the story of the trauma and overvalue their assumptions on the consumer
55Subjective Unit of Distress Scale (SUDS) Therapeutic Window4-7Image: “The Feeling Thermometer” chart
56PTSD Protective Factors PTSD is a failure of natural recovery with both risk factors and protective factors.Social support is a key mediating factorBelieving and validating the experienceFeeling good about one’s own actions in the face of dangerCognitive and self-regulation abilitiesPositive belief about oneselfMotivation to act effectively in environment
57Factors to Consider for Treatment Planning How trauma history is impacting current behaviorHow triggers/reminders are impacting behaviorEstablish purpose for a trauma-specific interventionBe mindful of ongoing trauma and environmental risksConsumer to establish goalsThat address symptoms and functionThat take into consideration the power of avoidanceThat respect meaning making and copingThat start from a strengths perspectiveClear roles for consumer and clinician over the course of the intervention and the value of community supportsImage: Unlatched chest
58Risks of Not Treating Trauma-Related Disorders Consumer not heard, valued, understoodMost trauma-specific disorders are treatableThe trauma-specific distress can disrupt functioning and exacerbate co-occurring disordersMissed opportunity for human connectionsMissed chance for meaning making
60Trauma-Specific Services in a Recovery-Oriented Practice Intervention choices in response to experiencing symptomsTo prevent or minimize symptomsTo manage or overcome the disorder
61Get to Know the Treatments Evidence-based/supported trauma txCBTTF–CBT; CTG–CBTCPTCPPTSTSTAIREMDRSPARCSTREMSeeking SafetyPE (Prolonged Exposure)MedicationOthers?Non-trauma-specific EBTs and non- EB treatments often used with traumatized consumersDBTMSTFFTSTEPPSPCITSomatic treatments (sensorimotor, somatic experiencing, yoga, etc.)Psychodrama therapyNarrative TherapyIPTOthers?
62Commonalities of Phased Trauma Treatments Safety and stabilization—preparatory phase; purpose is to restore and/or strengthen consumer’s sense of safety and coping skills, and can include the following. Elements of phase will be repeated and reinforced throughout the next two phases.Skills for affect and interpersonal regulationLearning and practice of coping, relaxation, and grounding techniquesPsychoeducationCognitive coping techniques, thought stopping, and attention shiftingProvides opportunity for consumer and clinician to build a therapeutic allianceMakes use of spirituality and safe connections
63Phase One: Safety and Stabilization (cont’d) Managing EmotionsAffective education and regulationGrounding techniquesBreathing retrainingProgressive muscle relaxationImagerySelf-talkContainment and distraction
64Phase One: Safety and Stabilization (cont’d) Feeling IdentificationIdentification of affect and intensityLabeling feelingsIdentification of connection between feeling, thoughts, and behaviorsIdentification of how consumers experience distress, such asBody: where the distress is located in their bodies. (Those who dissociate don’t necessarily experience distress this way.) Sense of body in space.Racing thoughtsGroundingNecessary first step for affect regulation and active copingEarly, temporary way to manage and contain overwhelming feelings by focusing on a specific sensory pathway for containment
65Commonalities of Phased Trauma Treatments 2. Remembrance and mourning—provides some form of exposure therapy whereby traumatic events are recalled and cohesively assembled. This phase helps end cycle of PTSD (and is done when it is POST trauma). Exposure can include the followingCreation of trauma narrativeProcessing and integration of traumatic experiencesDesensitization through repeated telling of trauma story and/or exposure to fears or aspects avoidedAddressing 1 & 2 distorted cognitions
66Commonalities of Phased Trauma Treatments 3. Reconnection—emotions and cognitions revealed during the exposure phase are examined; treatment moves beyond trauma experience and is connected to consumer’s interpersonal lifeIdentification and modulation of cognitive distortionsMeaning makingProcessing and integration of trauma experiencePreparation for returning to daily lifeCoping with real losses as a result of the trauma(s)
67Shared Characteristics of EB and Promising Practices Function as service components within systems of careAre provided in the communityUtilize natural supports and partner with families, with training and supervision provided by those with formal trainingOperate under the auspices of all systems serving children, adults, and familiesIntegrated with other treatment interventionsRecovery-oriented focus
69Secondary Traumatic Stress Secondary Traumatic Stress is a natural, normal, potential effect of empathic engagement with a traumatized person.Doing our job puts us at risk for secondary trauma.
70Different Levels of Effects First order Effects—Lower levelBelief systemsPersonal control and invulnerabilityPersonal competenceLive in a just and benevolent worldGoodness of othersHigher level—Effects mimic typical PTSD symptomsRe-experiencingNumbing/arousalHyperarousal
71Risk FactorsDegree of Exposure—(thought to be the primary risk factor)qualitative and quantitative/cumulativeIntensity of work demand/stress overloadPersonal history of traumaLack of social support/isolationPunitive work environmentLack of appropriate and supportive supervisionExposure to acts of terrorism and violence outside of work
73Enact BalanceOutlays of Energy … Balanced by … Replenishment of EnergyImage: Balance scale(Mary Jo Barrett, 2009)
74Personal Self-Care Within the Workplace Pacing—time management skillsBuild in time to talk to colleagues and have a collegial support system in placeBuild a personal sense of safety and de-stress: take breaks—even for a few minutes at a time, eat lunch, walk, breathe, don’t answer every call immediately, flowers in office, music you likeUtilize supervision and crisis helpManaging and tolerating the strong effects raised in the course of this workReview your caseload—how many consumers have trauma histories? Can changes be made moving forward?
75Personal Self-Care Outside the Workplace Consider therapy for unresolved trauma, which the therapeutic work may be activatingPractice stress management through meditation, prayer, conscious relaxation, deep breathing, and exerciseKeep in contact with trusted othersEngage in hobbies and enjoyed activitiesGet quiet timeDevelop a written plan focused on maintaining work–life balance
76Contact InformationPaula G. Panzer, M.D. Jewish Board of Family and Children’s Services New York, N.Y. Center for Trauma Program Innovation Martha K. Selig Educational Institute
77The Trauma of Delusions Eric Arauz, MLERThe Trauma of DelusionsEric Arauz, MLER Arauz Inspirational Enterprises
78The Trauma of Delusions Image: Pablo Picasso’s “Guernica”
79…this led to a lifelong phobia of sharks. While in a manic episode, a man had a recurring delusion of a shark attack…Image: Man being attacked by shark…this led to a lifelong phobia of sharks.
80The Blasphemy of ManiaImage: “Man of Fire,” Jorge Orozco
81Religious Feeling Emulates Sickness Mental illness has stolen God from me …
82Recovery“The patient must find the courage to direct his attention to the phenomena of his illness. His illness must no longer seem to him contemptible, but must become enemy worthy of his mettle, a piece of his personality, which has solid ground for its existence, and out of which things value for his future life have to be derived.” —Sigmund Freud (from Trauma and Healing, Dr. Judith Herman)
83“Art, not psychology, is the language of emotions.” Image: “The Madhouse,” Francisco de GoyaCritique of Religion and Philosophy (1958), Walter Kaufmann
84Language of Madness Language of the heart: addiction Alternative to clinical languageFeel versus logicSubjective versus objective
85Resources for Practitioners Frankenstein (1818), Mary Shelley: Created by doctors; conscious of his otherness to society; stigmatized as monsterDiary of a Madman (1835), Nikolai Gogol: Narrative of delusions; elucidates the progression of madnessHamlet (1603), William Shakespeare: Duality of mind; aware that thought may not be soundThe Metamorphosis (1915), Franz Kafka: Experience of turning into something your family fears and does not understand; what it can feel like after hospital“Freak on a Leash” (1998), Korn: “Something takes a part of me, Something lost and never seen, Every time I start to believe, Something’s raped and taken from me, from me”; hyperarousal of biological disease
86Eric Arauz, MLER President, Arauz Inspirational Enterprises LLC Adjunct Instructor, Psychiatry: Robert Wood Johnson Medical SchoolSpecial State Officer, N.J. Governor’s Council on Alcoholism and Drug AbuseNew York Times ContributorInternational Trauma Trainer2009 SAMHSA/U.S. Department of Health and Human Services “Voice Award” recipient for National AdvocacyLecturer at SAMHSA, NASMHPD, Yale University, Purdue University, Bristol–Myers Squibb, etc.Featured on ABC’s Good Morning America “Now–Mind and Mood” specialKeynote 2010 American Psychiatric Nurses Convention in Louisville, K.Y.; numerous national keynotesDisabled American veteran who served in U.S. Navy in Operation Desert Shield
88Q&A, Discussion, and Summary To ask a question, click on the Q/A tab and type your question in the window that opens, or press *1 for the operator, who will take your question in the order in which it is received.Larry Davidson, Ph.D.Project Director, Recovery to PracticeDSG, Inc.Thanks for joining our Webinar today!Image: Photo ofLarry Davidson, Ph.D.
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