1. 1 By David Fuller, CPRP Florida Partners in Crisis 2011 Annual Conference and Justice Institute “Leading Change, Inspiring Innovation” TRAUMA and RECOVERY: A SELFHELP APPROACH CONSUMER LEADERSHIP IN THE SUPPORT OF PEOPLE RECOVERING FROM TRAUMA

2. Presenter David Fuller, CPRP Forensic Peer Services Coordinator, New York Association of Psychiatric Rehabilitation As an administrator, service provider, and independent consultant, Mr. Fuller is an agent of change, and draws on personal experience as a consumer—and the opportunity to overcome many challenges— to fuel his mission of improving access to services for people who have been affected by psychiatric diagnoses, substance abuse and use the public mental health system; for this reason he was called before the United States Senate Sub Committee on Human Rights to testify on the subject of incarceration and mental illness. David has been a guest lecturer at the Columbia, NYU, Hunter, and Adelphi Schools of Social Work on Trauma and Recovery. 2

3. 3 What is Trauma and Why Must We Address It?

4. 4 What is Trauma? Definition (NASMHPD, 2006) 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) DSM IV-TR (APA, 2000) – Person’s response involves intense fear, horror and helplessness – Extreme stress that overwhelms the person’s capacity to cope

5. What is Trauma Events/experiences that are shocking, terrifying, and/or overwhelming to the individual. Results in feelings of fear, horror, helplessness Triggering events may include witnessing, sensory exposure, media exposure What types of events are traumatic? 5

6. What is Trauma Pre and Perinatal Trauma Pre and Perinatal Trauma Single Episode Trauma Single Episode Trauma Developmental or Complex Trauma Developmental or Complex Trauma Historical Trauma Historical Trauma 6

7. Types of Trauma Resulting in Serious Mental Illness Are usually not a “single blow” event e.g. rape, natural disaster Are interpersonal in nature: intentional, prolonged, repeated, severe Occur in childhood and adolescence and may extend over an individual’s life span (Terr, 1991; Giller, 1999) 7

8. What does trauma do? Trauma changes the way people perceive reality. Trauma shapes a child’s basic beliefs about identity, world view, and spirituality. Using a trauma framework, the effects of trauma can be addressed and a person can go on to lead a “normal” life. Symptoms are ADAPTATIONS 8

9. 9 Definition of Trauma Informed Care Mental Health Treatment that incorporates: – An appreciation for the high prevalence of traumatic experiences in persons who receive mental health services – A thorough understanding of the profound neurological, biological, psychological and social effects of trauma and violence on the individual (Jennings, 2004)

10. Prevalence of Trauma Mental Health Population 90% of public mental health clients have been exposed (Muesar et al., in press; Muesar et al., 1998) Most have multiple experiences of trauma 34-53% report childhood sexual or physical abuse (Kessler et al., 1995; MHA NY & NYOMH, 1995) 43-81% report some type of victimization 10

11. Prevalence of Trauma Mental Health Population – Adults Study in South Carolina CMHC found 91% of clients had histories of trauma (Cusack, Frueh & Brady, 2004) 97% of homeless women with SMI have experienced severe physical & sexual abuse – 87% experience this abuse both in childhood and adulthood (Goodman et al, 1997) Majority of adults diagnosed BPD (81%) or DID (90%) were sexually or physically abused as children (Herman et al, 1989; Ross et al, 1990) 11

12. 12 Prevalence of Trauma Child Mental Health/Youth Detention Population - U.S. Canadian study of 187 adolescents reported 42% had PTSD Canadian study of 187 adolescents reported 42% had PTSD American study of 100 adolescent inpatients; 93% had trauma histories and 32% had PTSD American study of 100 adolescent inpatients; 93% had trauma histories and 32% had PTSD 70-90% incarcerated girls – sexual, physical, emotional abuse 70-90% incarcerated girls – sexual, physical, emotional abuse (DOC, 1998, Chesney & Sheldon, 1991)

13. 13 Prevalence of Trauma Substance Abuse Population – U.S. Up to two-thirds of men and women in SA treatment report childhood abuse & neglect (SAMSHA CSAT, 2000) Study of male veterans in SA inpatient unit – 77% 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 (Governor's Commission on Sexual and Domestic Violence, Commonwealth of MA, 2006)

14. Sexual Trauma and Addiction 208 African-American Women with histories of crack cocaine use Women with history of sexual trauma (n=134) reported being addicted to more substances than those who had not been sexually traumatized (n=74) Women with trauma histories reported more prior treatment failures than those without. (Young & Boyd, 2000) 14

15. What does the prevalence data mean? The majority of adults and children in psychiatric treatment settings have trauma histories as do children and adults served in a variety of 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) 15

16. 16 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 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 Severe medical conditions: heart disease, pulmonary disease, liver disease, STDs, GYN cancer Early Death Early Death (Felitti et al., 1998)

17. Adverse Childhood Experiences Study The Adverse Childhood Experiences (ACE) Study. ACE is a decade-long and ongoing collaboration between Kaiser Permanente’s Department of Preventive Medicine in San Diego and the Centers for Disease Control and Prevention (CDC). The ACE study was designed to assess the relationship between the childhood experiences and the current health status and health risk behaviors of 30,000 mainly middle-class adult members of Kaiser Permanente. To date, data have been collected from 19,000 cooperating adults. 17

18. Adverse Childhood Experiences Study The study indicates that childhood abuse and household dysfunction lead to the development— decades later—of the chronic diseases that are the most common causes of death and disability in this country, including heart disease, cancer, stroke, diabetes, skeletal fractures, chronic lung disease, and liver disease. A strong relationship is shown between the number of adverse childhood experiences and reports of cigarette smoking, obesity, physical inactivity, alcoholism, drug abuse, depression, suicide attempts, sexual promiscuity, and sexually transmitted diseases. 18

19. Adverse Childhood Experiences Study Furthermore, persons who reported higher numbers of adverse childhood experiences were much more likely to have multiple health risk behaviors. Similarly, the more adverse childhood experiences reported, the more likely the person was to develop chronic and disabling illnesses. Traditionally viewed as public health or mental health problems, these behaviors appear to be coping mechanisms for people who have had adverse childhood experiences, the study found. Authors suggest the behaviors may also reflect the effects of the adverse experiences on the developing brain chemistry—effects that may lead to the adoption of the coping behaviors (www.acestudy.org). 19

20. 20 Adverse Childhood Experiences – Recurrent and severe physical abuse – Recurrent and severe emotional abuse – Sexual abuse Growing up in household with: Growing up in household with: – Alcohol or drug user – Member being imprisoned – Mentally ill, chronically depressed, or institutionalized member – Mother being treated violently – Both biological parents absent – Emotional or physical abuse (Fellitti et al, 1998)

21. 21 ACE Study “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 heroin 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 et al, 1998) “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 heroin 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 et al, 1998)

22. 22 ACE Study Is drug abuse self-destructive or is it a desperate attempt at self-healing, albeit while accepting a significant future risk?” (Felitti, et al, 1998) Is drug abuse self-destructive or is it a desperate attempt at self-healing, albeit while accepting a significant future risk?” (Felitti, et al, 1998)

23. 23 ACE Study “ Addiction is best viewed as an understandable, unconscious, compulsive use of psychoactive materials in response to abnormal, prior life experiences, most of which are concealed by shame, secrecy, and social taboo.” (Felitti et al, 1998) “ Addiction is best viewed as an understandable, unconscious, compulsive use of psychoactive materials in response to abnormal, prior life experiences, most of which are concealed by shame, secrecy, and social taboo.” (Felitti et al, 1998)

24. 24 What does the prevalence data tell us? The majority of adults and children in psychiatric treatment settings have trauma histories The majority of adults and children in psychiatric treatment settings have trauma histories A sizable percentage of people with substance use disorders have traumatic stress symptoms that interfere with achieving or maintaining sobriety A sizable percentage of people with substance use disorders have traumatic stress symptoms that interfere with achieving or maintaining sobriety A sizable percentage of adults and children in the prison or juvenile justice system have trauma histories A sizable percentage of adults and children in the prison or juvenile justice system have trauma histories (Hodas, 2004, Cusack et al., Mueser et al., 1998, Lipschitz et al., 1999, NASMHPD, 1998)

25. 25 What does the prevalence data tell us? Growing body of research on the relationship between victimization and later offending Growing body of research on the relationship between victimization and later offending Many people with trauma histories have overlapping problems with mental health, addictions, physical health, and are victims or perpetrators of crime Many people with trauma histories have overlapping problems with mental health, addictions, physical health, and are victims or perpetrators of crime Victims of trauma are found across all systems of care Victims of trauma are found across all systems of care (Hodas, 2004, Cusack et al., Muesar et al., 1998, Lipschitz et al., 1999, NASMHPD, 1998)

26. 26 Therefore…… We need to presume the clients we serve have a history of traumatic stress and exercise “universal precautions” by creating systems of care that are trauma-informed (Hodas, 2005)

27. What you’ll see in Participants/Clients Aggression and low impulse control in new situations or with new people Power struggles and fear in the context of rule enforcement Disengagement as means of defense Interpretation of safety enforcement as predatory “Minor” events precipitating catastrophic reactions 27

28. What you will see in Treatment Providers Often have their own traumatic histories, including historical trauma Seek to avoid re-experiencing their own emotions Respond personally to others’ emotional states Perceive behavior as personal threat or provocation rather than as re-enactment Perceive client’s simultaneous need for and fear of closeness as a trigger of their own loss, rejection, and anger 28

29. 29 Trauma Informed Non Trauma Informed Trauma Informed Non Trauma Informed Recognition of high prevalence of trauma Recognition of high prevalence of trauma Recognition of primary and co- occurring trauma diagnoses Recognition of primary and co- occurring trauma diagnoses Assess for traumatic histories & symptoms Assess for traumatic histories & symptoms Recognition of culture and practices that are re-traumatizing Recognition of culture and practices that are re-traumatizing Lack of education on trauma prevalence & “universal” precautions Lack of education on trauma prevalence & “universal” precautions Over-diagnosis of Schizophrenia & Bipolar D., Conduct D. & singular addictions Over-diagnosis of Schizophrenia & Bipolar D., Conduct D. & singular addictions Cursory or no trauma assessment Cursory or no trauma assessment “Tradition of Toughness” valued as best care approach “Tradition of Toughness” valued as best care approach

30. 30 Trauma Informed Non Trauma Informed Trauma Informed Non Trauma Informed Power/control minimized - constant attention to culture Power/control minimized - constant attention to culture Caregivers/supporters – collaboration Caregivers/supporters – collaboration Address training needs of staff to improve knowledge & sensitivity Address training needs of staff to improve knowledge & sensitivity Keys, security uniforms, staff demeanor, tone of voice Keys, security uniforms, staff demeanor, tone of voice Rule enforcers – compliance Rule enforcers – compliance “Patient-blaming” as fallback position without training “Patient-blaming” as fallback position without training

31. 31 Trauma Informed Non Trauma Informed Staff understand function of behavior (rage, repetition-compulsion, self-injury) Staff understand function of behavior (rage, repetition-compulsion, self-injury) Objective, neutral language Objective, neutral language Transparent systems open to outside parties Transparent systems open to outside parties Behavior seen as intentionally provocative Behavior seen as intentionally provocative Labeling language: manipulative, needy, “attention-seeking” Labeling language: manipulative, needy, “attention-seeking” Closed system – advocates discouraged Closed system – advocates discouraged (Fallout & Harris, 2002; Cook et al., 2002, Ford, 2003, Cusack et al., Jennings, 1998, Prescott, 2000)

32. TRAUMA INFORMED PRACTICE VS. TRADITIONAL APPROACH Trauma-Informed Collaborative relationship Integrated whole person view of individual and context (complexity of people’s lives) “Symptoms” are seen as coping strategies (ACE Study) Primary goals are empowerment, recovery, and self-determination (building on strengths, expertise of lived experience) Traditional Hierarchical relationship Each system has its own view of the person and his/her “problems” Problems and symptoms are synonymous Primary goals are stability and absence of symptoms 32

33. FOCUS ON TRAUMA INFORMED PRACTICE Commitment and involvement from top leadership (Champions) with a consistent message. Identification of a person/group responsible for ongoing training and education of the staff and participants (Champions) (participant’s trauma-informed bill of rights) Part of supervision structure  One can’t give what they are not getting  Principles and practice of trauma-informed apply across the agency (at all levels, from the receptionist to the Board of Directors) Part of agency plan (long-term commitment) 33

34. TRAUMA INFORMED PRACTICE Includes understanding of prevalence, impact, and recovery Belief that recovery is possible for all Understands intergenerational aspect of trauma Focuses on “what happened” not “what’s wrong” Based on understanding of healing relationships (healing happens in relationships) Seeks to eliminate re-victimization and re-traumatization Speaks to voice, choice, and control 34

35. 35 Trauma and Recovery A Peer Support Approach Utilizing Rational Emotive Behavioral Therapy Methods

36. What Is Needed? One Peer trained in the model Other peers who want to participate A place to meet Manual and supporting literature (Books by Albert Ellis) The ability to identify feelings or have the desire to learn. Commitment 36

37. 37 Trauma and Recovery Trauma profoundly changes the way we perceive and experience life. One out of two American Adults experience at least one traumatic event in their life. People with co-occurring mental health and substance abuse disorders it is almost a universal truth.

38. 38 Trauma and Recovery Some examples of Trauma are: Physical, Sexual, and Emotional Abuse; Violence, War, Homelessness, Severe Substance Abuse, Incarceration, Restraint, Seclusion, Poverty, Discrimination, Natural Disaster etc.. “You would be surprised at what human beings can adapt to!” Or Do They?

39. 39 Trauma and Recovery Trauma responses are attitudes and behaviors that helped people to survive their experiences. (hypervigilence,“antisocial behavior”) Mental illness, substance abuse Criminality Rational decision making has “left the building”

40. 40 Trauma and Recovery Emotions are almost always in control. “Avoid further pain at all costs” SO WHAT FINALLY HELPED!

41. 41 Trauma and Recovery Peer Support which is an evidence based practice combined with R.E.B.T. which is one of the original forms of modern CBT developed by Dr. Albert Ellis As the word “rational” implies we will be changing our thinking using facts to diminish negative beliefs and feelings We do this by using the “ABC Paradigm”

42. 42 Trauma and Recovery A) is the activating event B) is the belief/negative self-statement (irrational) C) negative emotional consequences D) combat with new positive/rational self- statement E) new/diminished feelings

43. Absolute Statements Usually the negative statements that cause our unwanted negative emotional consequences contain words that that do not leave room for compromise. If we can identify these words in our self-statements we can then begin to empower ourselves to take some real control over our emotional state 43

44. IRRATIONAL RATIONAL A) Someone moves in front of me during rush hour traffic B)“People always cut me off in traffic!” C) Frustration, Anger D) Sometimes people need to get in front of me to get where they are going. E) annoyed, maybe understanding Example 44

45. Uncompromising Compromising Can’t Won’t Never Always All Every time Everyone Totally Sometimes Occasionally Some A Few From time to time Once in awhile Maybe Words 45

46. 46 Trauma and Recovery Most “therapies” goal is to make the person feel better but it does not fix the problem. REBT taught by a Credible Role Model (PEER Support) teaches a person a concrete skill that they can use to attempt to change the way they think and behave. It takes action on the part of the participant which encourages empowerment.

47. Trauma and Recovery “Emotional Literacy” The ability to “read and comprehend” yourself To make sense of our “inner space” we need to be able to attach words to our feelings so that we can communicate our needs to others, and understand ourselves 47

48. 48 Trauma and Recovery THINGS TO REMEMBER: Trauma changes the way you perceive life The focus is safety and avoiding pain, not being rational Women are usually looking to be empowered, Men are usually looking for permission to express their feelings You must start asking people what happened to them? Not what is wrong with them.

49. RESOURCES The Essence of Rational Emotive Behavior Therapy, by Albert Ellis, Ph.D. Revised, May 1994.) www.stopstigma.samhsa.gov/archtelpdf/PeerSu pport_Presentation.ppt 49

50. 50 Trauma and Recovery For further questions please contact: David Fuller, CPRP Email-davidf@nyaprs.org NYAPRS 1 Columbia Place Albany, NY 12207