1. Understanding Trauma and Why we Must Address It Office of Mental Health Original presentation: March 2010

2. 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. The presentation has been updated to include DSM-5 definitions.

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

4. 4 Trauma-Informed Care: Competency Assessment Ask if your organization… Does More Harm Lacks Capacity Is Trauma-Neutral Is Trauma-Sensitive Is Trauma-Informed Is Trauma-Proficient

5. 5 What is Trauma? 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 DSM-5 (APA 2013): The previous edition, DSM-IV, had addressed PTSD as an anxiety disorder. The DSM-5 includes a new chapter on Trauma- and Stressor-Related Disorders. Trauma includes: direct experience of the traumatic event; witnessing the traumatic event in person; learning that the traumatic event occurred to a close family member or close friend (with the actual or threatened death being either violent or accidental); or experiences first-hand repeated or extreme exposure to aversive details of the traumatic event (not through media, pictures, television or movies unless work-related).

6. 6 Traumas Most Likely To Lead to Serious Mental Health Problems in Youth: Sexual & physical abuse, neglect, emotional abuse, abandonment, poverty, sudden and traumatic loss A severe one-time or repeated event (Yes, even just once) Actions perpetrated by someone known Acts that betray trust Generally speaking, the most harmful trauma experiences tend to be those that were perpetrated by someone close - someone well-known to the victim - and/or were: Intentional Repeated Prolonged And the earlier in life it happened, the more profound the impact on brain development.

7. 7 One-time events can be as traumatic as repeated events. We do not want to minimize single occurrences like a rape, a serious automobile accident, or being involved in a natural disaster, like Hurricane Katrina or Irene, or Superstorm Sandy. Obviously these types of events can be devastating.

8. 8 Prevalence of Trauma Mental Health Population - US 90% of public mental health clients have been exposed to trauma Muesar et al., 2004. Muesar et al., 1998 51-98% of public health clients have been exposed to trauma Goodman et al., 1997. Muesar et al.,1998 Most have multiple experiences with trauma Muesar et al., 2004. 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

9. 9 Prevalence of Trauma Child Mental Health/Youth Detention - US Canadian study of 187 adolescents: 42% had PTSD American study of 100 adolescent inpatients: 93% had trauma histories and 32% had PTSD 70-90% of incarcerated girls had experienced sexual, physical and emotional abuse Doc. 1998. Chesney & Sheldon, 1991

10. 10 What does this tell us? 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 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

11. 11 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

12. 12 Learned Response Brain chemistry/development affected by trauma Immediate “fight or flight” response Heightened sense of fear/danger Scientists have studied the brains of people who have experienced trauma and have noted that the ability to regulate response is drastically effected. They seem to always to be in a state of high alert, ready to “fight or flight” - to protect themselves from remembered harmful experiences. This is their automatic, learned response. Our task is to help the person learn new ways of responding. Have you ever heard the term “speechless terror,” when people are unable to speak in times of great stress? That happens when traumatic memories shut down the part of the brain that instigates response.

13. 13 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.

14. 14 Typical Trauma-related Symptoms Dissociation Flashbacks Nightmares Hyper-vigilance Terror Anxiety Pejorative auditory hallucinations Difficulty w/problem solving Numbness Depression Substance abuse Self-injury Eating problems Poor judgment and continued cycle of victimization Aggression What we want you to understand is that these “symptoms” are not signs of pathology - rather, they are survival strategies that have helped them cope with terrible pain and challenges. The key is learn how the behavior developed and teach new coping strategies.

15. 15 Typical Trauma-related Symptoms Triggers are sights, sounds, smells, and touches, that remind the person of the trauma. Flashbacks are recurring memories, feelings, and thoughts. Traumatic stress brings the past to the present. The memory of the traumatizing event can trigger a response of intense fear, horror and helplessness in which extreme stress overwhelms one’s capacity to cope. We must be aware of the negative impact that exposure to those or people, places or things can have in triggering or re- traumatizing. For example, a dark room may trigger a memory of abuse in a dark room. Just hearing a voice similar to the abuser’s may create a crisis situation for the child.

16. 16 Posttraumatic Stress Disorder (PTSD) is a trauma diagnosis Criterion A (one required): A stressor Criterion B (one required): Intrusion symptoms Criterion C (one required): Avoidance Criterion D (two required): Negative alterations in cognitions and mood Criterion E (two required): Alterations is arousal and reactivity Criterion F: Duration (B, C, D, and E for more than one month) Criterion G: Functional significance Criterion H: Exclusion (not due to meds, substance use, or other illness Individuals may also experience dissociative symptoms and/or delayed expression. http://www.ptsd.va.gov/professional/PTSD- overview/dsm5_criteria_ptsd.asp

17. 17 Many of you have heard of PSTD associated with soldiers returning from combat. These folks have personally experienced and/or witnessed dreadful things. The children we work with often have a diagnosis of PSTD. Traumatic events that may trigger PTSD include violent personal assaults, natural or human-caused disasters, accidents, or military combat. We should note that family, other children and staff who witness or participate in restraint and seclusion can suffer from PTSD.

18. 18 Effects of a traumatic event may occur a few hours, several days, or a month after exposure to traumatic events, including after restraint or seclusion. Trauma symptoms would be present. PTSD may develop if symptoms continue and if left untreated. Our work in TIC will help alleviate the symptoms and potential of developing PTSD.

19. 19 Critical Trauma Correlates 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) Severe medical conditions: heart disease, pulmonary disease, liver disease, sexually transmitted infections, cancers Early death

20. 20 Adverse Childhood Experiences Recurrent and severe physical abuse Recurrent and severe emotional abuse Sexual abuse Growing up in a household with:  An alcohol or drug abuser  Someone who is or had been imprisoned  Someone with a serious and persistent mental illness, chronic depression, or who is or had been institutionalized  A parent being treated violently  Both biological parents absent  Emotional or physical abuse

21. 21 http://www.acestudy.org/ The Adverse Childhood Experiences study of the effects of trauma on future health was result of collaboration of CDC and Kaiser Permanente. They wanted to find out if there were any commonalities in the backgrounds of high users of healthcare services, chronic illnesses, and early deaths. They asked participants about trauma in their childhood - about recurrent physical or emotional or sexual abuse, family substance abuse or incarceration, depression, or other mental health issues. The study revealed the following information pictured here in this pyramid.

22. 22 The more adverse/traumatic a childhood, the higher the health risk. Brain development, cognitive, and emotional abilities are influenced by trauma. This promotes high-risk behaviors such as substance abuse and sexual acting-out that in turn increase health issues and can lead to early death. In addition, just being in the mental health system can produce circumstances that affect long-term health and well-being. The ACE Study - Results

23. 23 Trauma-Informed Care Recognition of prevalence of trauma Assessment and treatment for trauma Focus on What happened to you? vs. What is wrong with you? Informed by current research Recognition that coercive environments are re-traumatizing Universal precautions apply to all!

24. 24 Trauma-Informed Care Recipient is center of his/her own treatment Recipient and family are empowered Wellness and self management are the goal Transparent and open to outside parties Power/control are minimized Staff are trained and understand function of behavior TIC respects and empowers the individual as the center of their own wellness!

25. 25 Trauma-Informed Care The focus is on collaboration - 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 person in finding solutions

26. 26 Trauma-Informed Language Person-centered Respectful - get permission to use first name Conscious of tone of voice and noise level Body language Helpful and hopeful Objective, neutral language

27. 27 Trauma-Informed Environment Respectful interaction Opportunities for individual “space” and activities Welcoming settings Person-centered signage In TIC, each person is appreciated and respected. Individuality and acknowledgement of individual needs is a priority. Open communication is signaled by an atmosphere where staff are approachable. Example: The use of “Do Not” signs and rules is transformed into helpful and encouraging verbiage.

28. 28 Non-Trauma-Informed Lack of education on trauma Over-diagnosis of schizophrenia, singular addictions, bipolar and conduct disorders Focus is on rule enforcement and compliance Behavior seen as intentionally provocative Labeling: “manipulative, needy, attention-seeking”

29. 29 Problems Associated with a Controlling Culture Focus is on staff, not the recipient Addressing a problem is built around staff and program convenience Rules become more important as staff knowledge about their origin erodes The person’s compliance and containment are mistaken as actual learning of new skills and/or real improvement

30. 30 Problems Associated with a Controlling Culture Minor violations often lead to control struggles Fosters a belief that privileges (rights) must be earned Reinforces a need to control the recipient Poorly trained staff who bully people into compliance are not identified or disciplined These same staff may be rewarded for maintaining safety or creating a quiet shift

31. 31 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.”

32. 32 What Happens when Traumatized People are Restrained or Secluded? Research studies have found that children who were secluded: Experienced vulnerability, neglect, shame Repeatedly express being reminded of their original abuse 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

33. 33 What Happens when Traumatized People are Restrained or Secluded? Felt they were being punished Were confused by staff use of force Did not feel protected from harm 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

34. 34 Trauma Assessment Purpose: Used to identify past or current trauma, violence, and abuse, and assess related sequelae Provides context for current symptoms and guides clinical approaches and recovery progress Informs the treatment culture to minimize potential for re- traumatization Cook et al., 2002; Fallot & Harris, 2002; Maine BDS, 2000

35. 35 Trauma Assessment Should minimally include: Type: sexual, physical, or emotional abuse or neglect, exposure to disaster Age: when the abuse occurred Who: 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. Cook et al., 2002; Fallot & Harris, 2002; Maine BDS, 2000

36. 36 Trauma Assessment Results and “positive responses” must be addressed in treatment planning or assessment is useless Interview is conducted upon intake or shortly after Importance of therapeutic engagement during interview cannot be over-emphasized For children, assessment through play and behavior observations Cook et al., 2002; Fallot & Harris, 2002; Maine BDS, 2000

37. 37 Core Elements in the Most Effective Treatment Programs Memory identification, processing and regulation Anxiety management Identification and alteration of maladaptive cognitions Interpersonal communication and social problem-solving Direct intervention in the home/community Appropriate use of medication Hodas, 2004

38. 38 Organizational Commitment to Trauma-Informed Care Adoption of a trauma-informed policy to include: Commitment to appropriately assess trauma Avoidance of re-traumatizing practices Key administrators on board Resources available for system modifications and performance improvement processes Education of staff prioritized Fallot & Harris, 2002; Cook et al., 2002

39. 39 Organizational Commitment to Trauma-Informed Care Unit staff can access expert trauma consultation Unit staff can access trauma-specific treatment if indicated Fallot & Harris, 2002; Cook et al., 2002

40. 40 Organizational Commitment to Trauma-Informed Care Assessment data informs treatment planning in daily clinical work Advance directives, safety plans and de-escalation preferences are communicated and used Power & Control are minimized by attending constantly to unit culture Fallot & Harris, 2002; Cook et al., 2002

41. 41 In Summary Appreciate high prevalence rates 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 Provide support and skill development