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M E R C Y L I F E P A C EW E S T S P R I N G F I E L D , M A
An Introduction to Trauma Informed Care in IDT
K A T A R I N A H A L L O N B L A D , M S , O T R / LC A R M A R T H E N S W I F T , M S W , L I C S W
Trauma: Definition
An event or situation that overwhelms the individual’s ability to cope (Allen. J. as cited in Giller, E. (1999)
It is the individual’s belief or perception that they are in danger that matters (Haven, T. 2016)
Overwhelming emotion and a feeling of utter helplessness (Haven, T. 2016)
There may or may not be bodily injury as a result of the event (Giller, 1999)
Experiences that may be traumatic
Single Events: natural disasters crimes (robbery, murder, sexual assault) surgeries deaths witnessing or directly experiencing violence
Chronic or repetitive experiences : Abuse by caregiver Caregiver neglect or denial of basic needs Combat Environmental violence (gang violence, community violence, war/conflict) Concentration camps, genocide Experiencing or witnessing domestic abuse Enduring deprivation Poverty Divorce and separation from a caregiver
Trauma is …
Subjective and individual (up to the perception of the individual)
More likely to cause lasting harm when it is repetitive and relational in nature
Damaging Effects of Trauma
Experiences more likely to cause serious psychological harm:
Experienced early in life
Result from abuse or neglect from a caregiver and/or someone the individual feels attached to
Happen over a longer period time and more than once
Are unpredictable in nature
The individual has limited or insufficient protective factors (family or non-family supports, education, socio-economic status, etc.)
Are purposeful or intended to cause harm on the part of the person inflicting pain/suffering
Post Traumatic Stress Disorder (PTSD)
DSM-V Diagnostic Criteria (abbreviated)
Section A Exposure to potentially traumatic event(s)
Section B Persistent re-experiencing of the event (flashbacks, nightmares, intrusive thoughts)
Section C Avoidance of potential triggers
Section D Negative thoughts/feelings that began or worsened following the event.
Section E Arousal and reactivity that began/worsened after the event (irritability, heightened
startle response, difficulty sleeping, etc.)
Symptoms last for more than 1 month, create distress or functional impairment, and are not explained by medication or injury.
(American Psychiatric Association, 2013)
Diagnosis vs Experience
Many adults have experienced traumatic events early or later in life but do not meet diagnostic criteria for PTSD
Trauma experienced early in life impacts individuals differently than trauma experienced later – it affects how the brain develops
Chronic Exposure to Extreme Stress
Natural alarm system no longer functions as it should.
Affects ability to sense safety.
Can diminish ability to trust others.
Results in emotional numbing and avoidance.
(Hopper, 2009)
Early Trauma – Long Term Effects
Individuals who experienced trauma before the age of 25 may:
Develop an expectation that bad things will happen to them
Have a hard time forming relationships with other people
Have difficulty managing or regulating feelings and behaviors
Have difficulty developing a positive sense of themselves
(Blaustein and Kinniburgh, 2010)
Human beings are driven for connection and survival
When basic needs are not met, we develop survival strategies (behaviors)
At the time , these strategies often make sense in context. Later they may seem dysfunctional.
Behavior as Means of Getting Needs Met
Adaptive Strategies
Adaptive behaviors that develop during childhood and persist into
adulthood may be interpreted as “symptoms”
Trouble calming oneself gets labelled agitation
Difficulty seeing the world as a safe place looks like paranoia
Difficulty trusting others is seen as paranoia (even when based
on experience)
Disorganized thinking is labelled psychosis
Expecting or allowing exploitation is called self-sabotage
(Giller, 1999)
Tools for Survival
Early trauma limits development of coping skills.
Without effective tools to manage, individuals may learn to:
Over control or shut down emotions
Manage feelings through arousal behaviors (verbal or physical aggression)
Manage feelings through overtly dangerous behaviors (substance use, self-injury)
(Blaustein and Kinniburgh, 2010)
Protective Factors
Supportive family environment
Nurturing parenting skills
Stable family relationships
Household rules and monitoring of the child
Parental employment
Adequate housing
Access to health care and social services
Caring adults outside family who can serve as role models or mentors
Communities that support parents and take responsibility for preventing abuse
(Trauma Survivors Network, 2017)
ACE Study
ACE = Adverse Childhood Experience
Joint project of Kaiser & CDC
17,000 HMO patients studied to examine relationship between
childhood stress and life long health
Average age of respondents: 51
2/3 report at least one ACE
20% report 3 or more ACEs
(Felitti, Anda et al., 1998)
ACE and Health
Graded dose-response between ACEs and negative health outcomes
4 or more ACEs:
Severe obesity (1.6 times more likely) Depression (4.6 times more likely) Alcoholism (7.4 times more likely ) Heart disease (2.2 times more likely) Any cancer (1.9 times more likely) Stroke (2.4 times more likely ) COPD (3.9 times more likely) Diabetes (1.6 times more likely)
)
(Child Welfare Information Gateway, 2013)
ACEACE Conclusion
Adverse childhood experiences are the most basic cause of health risk behaviors,
morbidity, disability, mortality, and
healthcare costs.
(Felitti & Anda, 2007)
Finding your ACE score
Self Assessment:
http://acestudy.org/the-ace-score.html
Why does this matter to PACE?
Trauma is common
A history of traumatic experiences predisposes a person to a
multitude of health, psychological, and substance use disorders.
Many of the people we label “difficult” may actually be in need of
a different approach.
PACE organizations are holistic and person-centered so uniquely
suited to address the long term effects of trauma.
Trauma-Informed Care
• You are not defective
• You are an injured person
• Your injuries are seen & understood
• Your efforts to cope are valued and validated
• You deserve compassion & care
(Helling, 2017)
Trauma and IDT
If a ppt cannot accept or receive “good care”, we tend to find
fault in them (label, dismiss, stigmatize).
Recognize risk of re-traumatization
Am I attuned to the needs of this ppt as a traumatized person?
How to read the signs of working relationship breaking down?
How to re-organize care so that the ppt can benefit from it?
Responsibility to change belongs to the provider/team
TIC Principles
SAMHSA’s six key principles of a trauma-informed care:
Safety
Trustworthiness and transparency
Peer support and mutual self-help
Collaboration and mutuality
Empowerment, voice, and choice
Cultural, historical, and gender issues
(SAMHSA’s Trauma and Justice Strategic Initiative, 2014)
Trauma-Informed Care
Strength-based vs symptom-based
Person-centered vs administration-centered
Cultivating capacities vs fixing problems
Participant empowering vs expert oriented
Eliciting collaboration vs coercive or manipulating
(Helling, 2017)
What Can You Do?
Strategies for care providers:
• Ask permission
• Provide predictability and choice (even a limited set of choices)
• Identify strengths and use them to support success
• Remain calm and non-judgmental
• Use Active Listening - Listen more than you speak
• Practice self-care and self-reflection
• Instead of asking “What is wrong with you?" ask “What happened to you?"
• Look for the need being met through the behavior
• Be aware of potential triggers for behaviors and develop strategies for minimizing
exposure and support
(Davis, R.; Maul, A.; Center for Health Care Strategies, Inc; March 2015)
Attunement
Attunement requires a curiosity and willingness to understand. Be more concerned with being caring than being right.
People don't solve problems when they are afraid or enraged. The time to solve the problem or analyze is not while the person is triggered.
Look for the feelings underneath the behavior.
Attunement and Curiosity
Curiosity is key: think why? What is this person feeling?
Is it possible this behavior is an attempt to cope in some way?
Imagine this person is in incredible pain, might you respond differently?
but…RESISTANCE: I want to get RESISTANCE: I want to get better, but …
Change can be costly
Change is full of uncertainty
Winning means losing
Resistance is typically fear or shame-based
Change can disrupt existing patterns & relationships
Resistance has a purpose
(Steele & Ogden, 2006)
Self-Care and Compassion Fatigue
The first step to being a responsive and attuned helper is being attuned to your own needs.
A regular self-care routine is necessary
Working with people who have experienced trauma can be emotionally draining and leave you feeling helpless at times.
Remember that the person you are trying to help may be in incredible pain. Don’t take it personally.
Having awareness about your own triggers can help you seek appropriate support and set personal boundaries.
Assessing your own level of stress
Professional Quality of Life Scale http://www.wendtcenter.org/wp-
content/uploads/ProQOL_5_English.pdf
Life Stress Test http://www.compassionfatigue.org/pages/lifestresstest.pdf
Progress towards TIC at MercyLIFE
Book club: The Body Keeps the Score (Van der Kolk, 2014)
Small committee to discuss how to implement TIC practices in MercyLIFE
Consulted with an expert in TIC
Webinar in TIC for all interested staff
Ongoing re-framing in team discussions about ppts
Presentation at Western Mass Elder-Care Conference
Presentation at NPA
Plan: All-staff training on staff development day
References
Blaustein, M. E., & Kinniburgh, K. M. (2010). Appendix A. In Treating Traumatic Stress in Children and Adolescents (pp. 249-254). New York, NY: Guilford Press.
Child Welfare Information Gateway. (2013). Long-term consequences of child abuse and neglect. Washington, DC: U.S. Department of Health and Human Services, Children’s Bureau. )
Davis, R., & Maul, A. (2015). Trauma-Informed Care: Opportunities for HighNeed, High-Cost Medicaid Populations (pp. 3-8, Rep. No. 031915). Center for Health Care Strategies.
Diagnostic and statistical manual of mental disorders: DSM-5. (2013). Washington, D.C.: American Psychiatric Association.
Giller, E. (1999). What Is Psychological Trauma? Retrieved January 10, 2017, from https://www.sidran.org/resources/for-survivors-and-loved-ones/what-is-psychological-trauma/)
Haven, T. J. (2016, Spring). Understanding and Responding to Trauma. Lecture at Westfield State University MSW Foundation Seminar, Westfield, MA
References (cont.)
SAMHSA's Concept of Trauma and Guidance for a Trauma-Informed Approach (Publication No. 14-4884). (2014, July). Retrieved January 06, 2017, from Substance Abuse and Mental Health Services Administration website: http://store.samhsa.gov/shin/content/SMA14-4884/SMA14-4884.pdf
Siegel, D. J. (1999). The developing mind: Toward a neurobiology of interpersonal experience. New York: Guilford Press.
Trauma Survivors Network by American Trauma Society. (2017). Risk and Protective Factors. Retrieved January 30, 2017, from http://www.traumasurvivorsnetwork.org/traumapedias/777
Van der Kolk, B. (1989). The Compulsion to Repeat the Trauma: Re-enactment, Revictimization, and Masochism. Psychiatric Clinics of North America, 12(2), 389-411. Retrieved January 12, 2017, from http://www.cirp.org/library/psych/vanderkolk/
Van der Kolk, B. A. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma. New York: Viking