1. Trauma Informed Debbie Spaeth, LMFT, LPC, LADC

2. Section I: Neurological Effects of Trauma Section II: Adverse Childhood Experiences Section III: Trauma Informed Care

3. Section I: Neurological Effects of Trauma

4. Prefrontal Cortex Top down guidance of attention and thoughts: Your conscious goals for the situation-and your values-determine what you focus on and what you think, including problem solving Inhibition of inappropriate actions: Stopping yourself before acting on an unhelpful impulse, going too far down a wrong path Regulating emotions: Decreasing the intensity of your feelings; reducing their grip on how you perceive things, think, and act Reality testing: Checking out whether perceptions are true or faulty.

5. PC: Non-Trauma Events Chosen and deliberate, mostly in conscious awareness

6. Trauma = Impaired PFC Stress chemicals basically turns it off Primitive brain takes control We cannot: control our attention, remember values, think logically Emotional/Sensory Memories Evolution origins:stop to think = death

7. Trauma = Amygdala in Charge Automatic, mostly happening outside of conscious awareness

8. Freeze, Flight or Fight Freeze: Assess situation to avoid trauma Flight: Avoid Trauma by leaving Fight: When Flight is impossible If fighting is useles, then: Dissociation Tonic Immobility

9. Peritraumatic Dissociation Brain’s defense against overwhelming sensations and emotions – automatic, without trying Parts of experience normally linked are ‘dis- associated’ ‘Blanked out’ or ‘spaced out,’ or in some way felt that I was not part of what was going on. Found that I was on ‘automatic pilot’ – I ended up doing things that I later realized I hadn’t actively decided to do. What was happening seemed unreal to me, like I was in a dream or watching a movie or a play. Felt disconnected from my body.

10. Tonic Immobility Tonic immobility is characterized by pronounced verbal immobility, trembling, muscular rigidity, sensations of cold, and numbness or insensitivity to intense or painful stimulation (Marks, 1991) Tonic Immobility is induced by conditions of fear and physical restriction, although it can also occur in the absence of the latter, so the important aspect may be the perceived inability to escape (Heidt, Marx, & Forsythe, 2005)

11. Section II: Adverse Childhood Experiences

12. CDC and Kaiser Permanente Collaboration Over a decade long and 17,000 people Looked at ACE effects over lifespan Largest study ever done on Trauma

13. Adverse Childhood Experience* ACE Categories (Birth to 18) Abuse of Child Abuse of Child Emotional abuse Emotional abuse Physical abuse Physical abuse Contact Sexual abuse Contact Sexual abuse Trauma in Child’s Household Trauma in Child’s Household Environment Environment Alcohol and/or Drug User Alcohol and/or Drug User Chronically depressed, emotionally Chronically depressed, emotionally disturbed or suicidal household disturbed or suicidal household member member Mother treated violently Mother treated violently Imprisoned household member Imprisoned household member Not raised by both biological Not raised by both biological parents parents (Loss of parent – best by death (Loss of parent – best by death unless suicide, - Worst by unless suicide, - Worst by abandonment) abandonment) Neglect of Child Neglect of Child Physical neglect Physical neglect Emotional neglect Emotional neglect * Above types of ACEs are the “heavy end” of abuse. *1 type = ACE score of 1 Impact of trauma and health risk behaviors to ease the pain Neurobiologic Effects of Trauma Disrupted neuro-development Disrupted neuro-development Difficulty controlling anger/rage Difficulty controlling anger/rage Hallucinations Hallucinations Depression - other MH Disorders Depression - other MH Disorders Panic reactions Panic reactions Anxiety Anxiety Multiple (6+) somatic problems Multiple (6+) somatic problems Sleep problems Sleep problems Impaired memory Impaired memory Flashbacks Flashbacks Dissociation Dissociation Health Risk Behaviors Smoking Smoking Severe obesity Severe obesity Physical inactivity Physical inactivity Suicide attempts Suicide attempts Alcoholism Alcoholism Drug abuse Drug abuse 50+ sex partners 50+ sex partners Repetition of original trauma Repetition of original trauma Self Injury Self Injury Eating disorders Eating disorders Perpetrate interpersonal violence Perpetrate interpersonal violence Long-term consequences of unaddressed trauma (ACEs) Disease and Disability Ischemic heart disease Ischemic heart disease Cancer Cancer Chronic lung disease Chronic lung disease Chronic emphysema Chronic emphysema Asthma Asthma Liver disease Liver disease Skeletal fractures Skeletal fractures Poor self rated health Poor self rated health Sexually transmitted disease Sexually transmitted disease HIV/AIDS HIV/AIDS Serious Social Problems Homelessness Homelessness Prostitution Prostitution Delinquency, violence, criminal Delinquency, violence, criminal Inability to sustain employment Inability to sustain employment Re-victimization: rape, DV, bullying Re-victimization: rape, DV, bullying Compromised ability to parent Compromised ability to parent Negative alterations in self perceptions and relationships with others Negative alterations in self perceptions and relationships with others Altered systems of meaning Altered systems of meaning Intergenerational trauma Intergenerational trauma Long-term use of multiple human Long-term use of multiple human service systems service systems

15. Higher ACE = Higher Rates of Severe/Persistent emotional problems Health Risk Behaviors Serious Social Problems Adult Disease/Disability High Health, BH, Corr, Soc Serv, Costs Poor Life Expectancy

16. Tragic Consequences of Unaddressed Childhood Trauma Anna at 1.5 yoa Anna yrs later in a mental institution

17. ACE Consequences 67% of all suicide attempts 64% of adult suicide attemps 80% of child/adolescent suicide attemps

18. Substance Abuse Childhood Experiences and Alcoholism ACE score and Intravenous Drug Use

19. Effect of ACEs on Mortality 0 ACE 60% live to 654 ACE <3% live to 65

20. Cost to Society Annual Direct Cost: hospitalization, MH and Health care, CW, Law Enforcement = $33,101,302,133 Annual Indirect Cost: special educ, juvenile delinquency, MH and Health care, DOC/Jail, Lost Productivity = $70,652,715,359 Total Annual Cost = over $184 million per day Economic Impact Study (Sept 2007) Prevent Child Abuse America

21. Section III: Trauma Informed Care

22. Is both a philosophy and methodology Evidenced Based (20 yrs) Based on the ACEs Study Early Intervention = Decreased Negative Consequences in Neurological Functions

23. Trauma Informed Care A change of practice to consumer- driven care; based on hope, self-determination, and empowerment. Importance of listening to and hearing the lived experiences of trauma survivors, consumer-driven guided by people with a lived experience. They know better than anyone else what helps and what hurts in recovery.

24. Creating the TI Culture Avoid Re-Traumatization of clients and staff Culture of physical and emotional safety for clients and staff Belief that all have capacity for progressive change, but overwhelming stressors/traumatic experiences can derail this by developing maladaptive coping skills that make sense in the context of what happened, but does not make sense (and is not healthy) in their lives today. Surfacing and Resolving Conflicts while emphasizing choices & control Promoting and Valuing Honest Communication Respecting everyone’s feelings and perspectives even when different

25. Creating TI Culture- Cont’d Maintaining/Supporting emotional regulation for self/others Extending Kindness/Compassion while maintaining healthy boundaries. Using a Strength Based approach that honors the belief that everyone is doing the best they know how. Cultivating a fun attitude/atmosphere and sense of joy amongst staff/clients about the work that has to be done. Using group process, prob solving, and creative idea sharing whenever feasible, for resolution of shared problems.

26. Environment A place to be calm A place to be quiet A place to remove stimuli A place for therapy A place to pray A place to regulate emotions

27. Agency Administration Be a model for change. Use data to monitor change and inform practice. Develop attitudes, behaviors and core competencies. Assess risk for violence. Be present on the units to model and witness change. Use tools to teach self-management of illness and emotions. Rigorously debriefing analysis of events that do occur. Complete inclusion of consumers in their own care. Recognize peer support as a vital component of the spirit of recovery.

28. Agency Culture Acknowledge that trauma and compassion fatigue experienced by staff impacts their willingness to change. Acknowledge that patient and staff safety have to be key point for staff. Acknowledge that the “management vs. front line staff” attitudes and perceptions have to change.

29. Consumer Care Develop key trust points w/patients Be on time Take time to talk & listen Work together on Tx Plan Pros and Consequences of Change Inform Px of changes in care before it happens.

30. Staff Core Principles Safety: Ensure physical and emotional safety of staff throughout our system of care. Trustworthiness: Administration must consistently relay procedures and expectations. Choice: Enhance staff choice in the control of the day to day work. Collaboration: Maximize collaboration and sharing of power. Empowerment: Provide skill building, find ways to empower staff and provide needed resources.

31. Staff Functions Be open to change. Assess for risk for violence or self harm. Use tools to teach self-management of illness and emotions. Rigorous debriefing & analysis of events that do occur. Complete inclusion of consumers in their own care. Peer support is a vital component of the spirit of recovery.

32. Patient Core Principles Safety: Ensure physical and emotional safety of patients throughout our system of care. Trustworthiness: Make tasks and expectations clear and maintain appropriate boundaries. Choice: Enhance patient choice and control. Collaboration: Maximize collaboration and sharing of power with patients. Empowerment: Provide skill building, find ways to empower patients, and provide needed resources.

33. Phase I: Safety & Stabilization Attention to basic needs: connection to resources, self-care, ID of support sys Educate: Trauma and Recovery process Develop regulation of emotion and self- soothing skills

34. Phase II: Processing & Grieving of Trauma Memories Goal: “Have the Px acknowledge, experience, and normalize the emotions/cognitions associated w/the trauma at a pace that is safe and manageable.” - (Luxenberg, Spinazzola, Hildago, Hunt & VanDerKolk, 2001)

35. Phase III: Reconnection Develop a firm/new sense of self Develop healthy and supportive relationships, spirituality, intimacy

36. Circle of Care in TIC

37. Resources Creating Trauma Informed Syst’: www.nctsn.orgwww.nctsn.org CDC ACE Study - www.cdc.gov/nccdphp/ACE/outcomes.htmwww.cdc.gov/nccdphp/ACE/outcomes.htm Damaging conseq of trauma: www.theannainstitute.orgwww.theannainstitute.org National Center for TI Care: www.samhsa.gov/nctic/traumawww.samhsa.gov/nctic/trauma Treatment & TIC: www.childwelfare.govwww.childwelfare.gov TIC: www.thenationalcouncil.orgwww.thenationalcouncil.org

38. THE END Debbie Spaeth, LMFT, LPC, LADC dspaeth@questmhsa.com 405-401-8234