Understanding Trauma and Why We Must Address It New York State Office of Mental Health March 2010

2 Acknowledgement The New York State Office of Mental Health wishes to acknowledge the contributions of the National Association of State Mental Health Program Directors (NASMHPD) and its Office of Technical Assistance (formerly NTAC) for many of the following slides.

Objectives Define Trauma and Trauma- Informed Care Define Trauma and Trauma- Informed Care Review Prevalence and Implications Review Prevalence and Implications Compare Trauma-Informed and Trauma-Insensitive Systems Compare Trauma-Informed and Trauma-Insensitive Systems Identify Core Elements of Organizational Commitment Identify Core Elements of Organizational Commitment 3

4 Trauma-Informed Care: Competency Assessment Does More Harm Does More Harm Lacks Capacity Lacks Capacity Trauma-Neutral Trauma-Neutral Trauma-Sensitive Trauma-Sensitive Trauma-Informed Trauma-Informed Trauma-Proficient Trauma-Proficient

What is Trauma? NASMHPD (2006) 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 disaster The experience of violence and victimization including sexual abuse, physical abuse, severe neglect, loss, domestic violence and/or the witnessing of violence, terrorism or disaster DSM IV-TR (APA 2000) DSM IV-TR (APA 2000) - Person’s response involves intense fear, horror, and helplessness - Person’s response involves intense fear, horror, and helplessness - Extreme stress that overwhelms ability to cope - Extreme stress that overwhelms ability to cope 5

Trauma Includes: Sexual & physical abuse, neglect, emotional abuse, abandonment, poverty, sudden and traumatic loss Sexual & physical abuse, neglect, emotional abuse, abandonment, poverty, sudden and traumatic loss A severe one time, or repeated event A severe one time, or repeated event Actions perpetrated by someone known Actions perpetrated by someone known Acts that betray trust Acts that betray trust

Prevalence of Trauma Mental Health Population-US 90% of public mental health clients have been exposed to trauma ( Muesar et al., Muesar et al., 1998) 90% of public mental health clients have been exposed to trauma ( Muesar et al., Muesar et al., 1998) 51-98% of public health clients have been exposed to trauma (Goodman et al., Muesar et al.,1998) 51-98% of public health clients have been exposed to trauma (Goodman et al., Muesar et al.,1998) Most have multiple experiences with trauma (Muesar et al., Muesar et al., 1998) Most have multiple experiences with trauma (Muesar et al., Muesar et al., 1998) 97 % of homeless women with SMI have experienced severe physical & sexual abuse, and 87% experience this abuse both in childhood and adulthood (Goodman et al., 1997) 97 % of homeless women with SMI have experienced severe physical & sexual abuse, and 87% experience this abuse both in childhood and adulthood (Goodman et al., 1997) 7

Prevalence of Trauma Child Mental Health/Youth Detention-US 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% of incarcerated girls - sexual, physical and emotional abuse 70-90% of incarcerated girls - sexual, physical and emotional abuse (Doc Chesney & Sheldon, 1991)

What Does This Tell Us? The majority of adults and children in psychiatric treatment settings have trauma history The majority of adults and children in psychiatric treatment settings have trauma history A sizeable percentage of people with substance abuse disorders have traumatic stress symptoms that interfere with maintaining stability A sizeable percentage of people with substance abuse disorders have traumatic stress symptoms that interfere with maintaining stability A sizable percentage of adult and children in the prison or juvenile justice systems have trauma histories A sizable percentage of adult and children in the prison or juvenile justice systems have trauma histories (Hodas 2004, Cusack et al., Mueser et al., Lipschitz et al, 1999, NASMHPD 1998) 9

Therefore… We need to presume that 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) 10

Learned Response Brain chemistry/development affected by trauma Brain chemistry/development affected by trauma Immediate “fight or flight” response Immediate “fight or flight” response Heightened sense of fear/danger Heightened sense of fear/danger

Typical Trauma-related Symptoms Dissociation Dissociation Flashbacks Flashbacks Nightmares Nightmares Hyper-vigilance Hyper-vigilance Terror Terror Anxiety Anxiety Pejorative auditory hallucinations Pejorative auditory hallucinations Difficulty w/problem solving Difficulty w/problem solving Numbness Numbness Depression Depression Substance abuse Substance abuse Self-injury Self-injury Eating problems Eating problems Poor judgment and continued cycle of victimization Poor judgment and continued cycle of victimization Aggression

Triggers and Flashbacks Triggers are sights, sounds, smells, and touches, that remind the person of the trauma. Triggers are sights, sounds, smells, and touches, that remind the person of the trauma. Flashbacks are recurring memories, feelings, and thoughts. Flashbacks are recurring memories, feelings, and thoughts. Traumatic stress brings Traumatic stress brings the past to the present. the past to the present.

Post Traumatic Stress Disorder (PTSD) Defined: The development of characteristic symptoms, following exposure to a traumatic stressor involving direct personal experience or witnessing another person’s experience of: The development of characteristic symptoms, following exposure to a traumatic stressor involving direct personal experience or witnessing another person’s experience of: Actual or threatened deathActual or threatened death Actual or threatened serious injuryActual or threatened serious injury Threat to physical integrityThreat to physical integrity

Critical Trauma Correlates Adverse Childhood Events (ACE’s) have serious health consequences Adverse Childhood Events (ACE’s) 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 15

Adverse Childhood Experiences Recurrent and severe physical abuse Recurrent and severe physical abuse Recurrent and severe emotional abuse Recurrent and severe emotional abuse Sexual abuse Sexual abuse Growing up in household with: Growing up in household with: Alcohol or drug userAlcohol or drug user Member being imprisonedMember being imprisoned Mentally ill, chronically depressed, or institutionalized memberMentally ill, chronically depressed, or institutionalized member Mother being treated violentlyMother being treated violently Both biological parents absentBoth biological parents absent Emotional or physical abuseEmotional or physical abuse 16

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Trauma-Informed Care Recognition of prevalence of trauma Recognition of prevalence of trauma Assessment and treatment for trauma Assessment and treatment for trauma Focus on what happened to you vs. what is wrong with you Focus on what happened to you vs. what is wrong with you Informed by current research Informed by current research Recognition that coercive environments are re-traumatizing Recognition that coercive environments are re-traumatizing

Trauma-Informed Care Recipient is center of his/her own treatment Recipient is center of his/her own treatment Recipient and family are empowered Recipient and family are empowered Wellness and self management are the goal Wellness and self management are the goal Transparent and open to outside parties Transparent and open to outside parties Power/control are minimized Power/control are minimized Staff are trained and understand function of behavior Staff are trained and understand function of behavior

Trauma-Informed Care The focus is on collaboration - The focus is on collaboration - Not engaging in interactions that are demeaning, disrespectful, dominating, coercive, or controlling Not engaging in interactions that are demeaning, disrespectful, dominating, coercive, or controlling Responding to disruptive behaviors with empathy, active listening skills and questions that engage the recipient in finding solutions Responding to disruptive behaviors with empathy, active listening skills and questions that engage the recipient in finding solutions

Trauma-Informed Language Person centered Person centered Respectful - get permission to use first name Respectful - get permission to use first name Conscious of tone of voice and noise level Conscious of tone of voice and noise level Body language Body language Helpful and hopeful Helpful and hopeful Objective, neutral language Objective, neutral language

Trauma-Informed Environment Respectful interaction Respectful interaction Opportunities for individual “space” and activities Opportunities for individual “space” and activities Welcoming settings Welcoming settings Person-centered signage Person-centered signage

Lack of education on trauma Lack of education on trauma Over-diagnosis of schizophrenia, singular addictions, bipolar and conduct disorders Over-diagnosis of schizophrenia, singular addictions, bipolar and conduct disorders Rule enforcement/compliance focus Rule enforcement/compliance focus Behavior seen as intentionally provocative Behavior seen as intentionally provocative Labeling: “manipulative, needy, attention- seeking ” Labeling: “manipulative, needy, attention- seeking ” Non-Trauma-Informed

Problems Associated with a Controlling Culture Focus is on staff, not the recipient Focus is on staff, not the recipient Addressing a problem is built around staff and program convenience Addressing a problem is built around staff and program convenience Rules become more important as staff knowledge about their origin erodes Rules become more important as staff knowledge about their origin erodes Compliance and containment are mistaken as actual learning of new skills by the recipient and/or real improvement Compliance and containment are mistaken as actual learning of new skills by the recipient and/or real improvement

Problems Associated with a Controlling Culture Minor violations often lead to control struggles Minor violations often lead to control struggles Fosters a belief that privileges (rights) must be earned Fosters a belief that privileges (rights) must be earned Reinforces a need to control the recipient Reinforces a need to control the recipient Poorly trained staff who bully recipients into compliance are not identified or disciplined Poorly trained staff who bully recipients into compliance are not identified or disciplined These same staff may be rewarded for maintaining safety or creating a quiet shift These same staff may be rewarded for maintaining safety or creating a quiet shift

Exercise Rephrase the following using Trauma- Informed language: “You need to get out of bed now!” “You need to get in line for lunch” “No, you can’t go back to your room”

27 What Happens when Traumatized Consumers are Restrained or Secluded? Research studies have found that children who were secluded: Experienced vulnerability, neglect, shame Experienced vulnerability, neglect, shame Repeatedly express being reminded of original abuse Repeatedly express being reminded of original abuse Express feelings of fear, rejection, anger and agitation (verbally and in drawings) Express feelings of fear, rejection, anger and agitation (verbally and in drawings) (Wadeson et al., 1976; Martinez, 1999; Mann et al., 1993; Ray et al., 1996)

28 What Happens when Traumatized Consumers are Restrained or Secluded? Felt they were being punished Felt they were being punished Were confused by staff use of force Were confused by staff use of force Do not feel protected from harm Do not feel protected from harm Report feelings of bitterness and anger one year later Report feelings of bitterness and anger one year later (Wadeson et al., 1976; Martinez, 1999; Mann et al. 1993; Mohr, 1999; Ray et al., 1996)

29 Trauma Assessment Purpose Purpose Used to identify past or current trauma, violence, and abuse, and assess related sequelaeUsed to identify past or current trauma, violence, and abuse, and assess related sequelae Provides context for current symptoms and guides clinical approaches and recovery progressProvides context for current symptoms and guides clinical approaches and recovery progress Informs the treatment culture to minimize potential for re-traumatizationInforms the treatment culture to minimize potential for re-traumatization (Cook et al., 2002; Fallot & Harris, 2002; Maine BDS, 2000)

30 Trauma Assessment Should minimally include: Should minimally include: Type: sexual, physical, or emotional abuse or neglect, exposure to disasterType: sexual, physical, or emotional abuse or neglect, exposure to disaster Age: when the abuse occurredAge: when the abuse occurred Who: perpetrated the abuseWho: perpetrated the abuse Assessment of such symptoms as: dissociation, flashbacks, hyper- vigilance, numbness, self-injury, anxiety, depression, poor school performance, conduct problems, eating problems, etc.Assessment of such symptoms as: dissociation, flashbacks, hyper- vigilance, numbness, self-injury, anxiety, depression, poor school performance, conduct problems, eating problems, etc.(Ibid)

31 Trauma Assessment Results and “positive responses” must be addressed in treatment planning or assessment is useless Results and “positive responses” must be addressed in treatment planning or assessment is useless Interview is conducted upon intake or shortly after Interview is conducted upon intake or shortly after Importance of therapeutic engagement during interview cannot be over- emphasized Importance of therapeutic engagement during interview cannot be over- emphasized For children, assessment through play and behavior observations For children, assessment through play and behavior observations(Ibid)

32 Core Elements in the Most Effective Treatment Programs Memory identification, processing and regulation Memory identification, processing and regulation Anxiety management Anxiety management Identification and alteration of maladaptive cognitions Identification and alteration of maladaptive cognitions Interpersonal communication and social problem-solving Interpersonal communication and social problem-solving Direct intervention in the home/community Direct intervention in the home/community Appropriate use of medication Appropriate use of medication (Hodas, 2004)

33 Organizational Commitment to Trauma-Informed Care Adoption of a trauma-informed policy to include: Commitment to appropriately assess trauma Commitment to appropriately assess trauma Avoidance of re-traumatizing practices Avoidance of re-traumatizing practices Key administrators on board Key administrators on board Resources available for system modifications and performance improvement processes Resources available for system modifications and performance improvement processes Education of staff prioritized Education of staff prioritized (Fallot & Harris, 2002; Cook et al., 2002)

34 Organizational Commitment to Trauma-Informed Care Unit staff can access expert trauma consultation Unit staff can access expert trauma consultation Unit staff can access trauma-specific treatment if indicated Unit staff can access trauma-specific treatment if indicated (Fallot & Harris, 2002; Cook et al., 2002)

35 Organizational Commitment to Trauma Informed Care Assessment data informs treatment planning in daily clinical work Assessment data informs treatment planning in daily clinical work Advance directives, safety plans and de- escalation preferences are communicated and used Advance directives, safety plans and de- escalation preferences are communicated and used Power & Control are minimized by attending constantly to unit culture Power & Control are minimized by attending constantly to unit culture (Fallot & Harris, 2002; Cook et al., 2002)

36 In Summary... Appreciate high prevalence rates Appreciate high prevalence rates Understand the characteristics of trauma-informed care and how this differs from care that is not informed by trauma Understand the characteristics of trauma-informed care and how this differs from care that is not informed by trauma Assess histories and symptoms of trauma and link to treatment plans/crisis plans Assess histories and symptoms of trauma and link to treatment plans/crisis plans Provide support and skill development Provide support and skill development