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!Rhonda!Craig,!MPA!
Mary!Vicario,!LPCC4S!!
Why$Care$About$Trauma?$! Definition((of(Trauma(
! An!experience!that!produces!psychological!injury!or!pain.!!(www.Dictionary.com)!!
! !Trauma!impacts!a!majority!of!individuals!in!the!DD!&!MH!systems!!! Statistics!are!startling!ranging!from!20470%,!but!all!agree!it!is!likely!under4reported!(Gentile,!2012)!
!! Myth:!!Trauma!as!the!latest!catch!all!
What$is$Safety$and$Why$Does$It$Ma:er?$$
Safety!is!the!Cornerstone!of!our!ability!to!Connect(and((Regulate.!!!!!
Mary!Vicario,!LPCC4S!! 3
Trauma$Impacts$People$in$Predictable$Ways:$! Impact(on(the(Brain((Schupp,!2004)!! Over!time!with!repeated!release!of!fight!or!flight!chemicals:!! The(cortexes(ability!to!plan,!organize,!and!execute!action!while!regulating!emotions!is!damaged.!
! The(amygdala(is!damaged!&!no!longer!accurately!recognizes!danger.!
! The(hippocampus(no!longer!effectively!tracks!memory,!controls!consciousness,!or!circadian!rhythms.!
! The(brainstem(misfires!causing!enuresis,!encopresis,!digestive!issues,!impulsive!aggression!from!an!over!active!startle!response.!
Trauma$Impacts$People$in$Predictable$Ways:$
! Impact(on(Development(! 50%!of!brain!development!occurs!after!birth!!
(Putnam,!2004)!
! Impact(on(Social,(Psychological,(and(Emotional(Regulation(! Emotional!development!begins!chemically!in!the!brain!at!six!months!gestation!(Schupp,!2004)!
! The!ability!to!trust,!and!the!brain!chemistry!connected!with!it,!begin!at!one!month!of!age.!
What$happens$when$we$ignore$trauma?$
! Disregard!of!trauma!and!its!impact!causes!additional!trauma!
! Constantly!putting!out!fires!! Reactive!rather!than!proactive!! Disregarding!trauma!causes!our!services!to!be!ineffective!
Crossing$the$Bridge$to$the$Neurobiological$Purpose$of$Behavior$
1.!!Attention !!
2.!!Escape!!!
3.!!Tangibles !!
4.!!Bored!
5.!!Pain!! ! !!
1.!!To!feel!connected,!accepted!&!loved!2.!!To!feel!safe!&!secure!3.!!To!have!some!say!in!
!your!life!4.!!To!have!a!purpose!in!
!life!5.!!We!are!ALL!HARDWIRED!to! !avoid!pain!
7!
Standing(in(the(middle(of(the(bridge…Traditional(View:(((((
Making(it(to(the(other(side…We(all(want:(((Burke,(2014)(
8
Top Five Resilience Factors 5. Autonomy (What do I have control over and how to make things happen?)
4. Self Esteem
Sense of Self – Personal Preferences (likes & dislikes) Sense of Self Worth – When do you feel loved and valued. Sense of Self-efficacy – How do I affect change? – How do I
make things happen? 3. External Support Systems (Can be a person, pet, fantasy) 2. Affiliation (with a cohesive supportive group) 1. YOU!
Positive Experiences with people outside their abusive environment, especially people in positions of authority
Trauma$Responsive$Services$ $$! Shift!from!!
! “What’s!wrong!with!you?”!!
! To:!! “What!happened!and(how(can(we(help?”!
! Two!Examples!from!Hamilton!County!! Trauma!Informed!Biographical!Timelines!
TraumaFInformed$Biographical$Timelines$! An(approach(for(building(empathy(and(creating(shared(understanding(of:(! The!person’s!trauma!history!! Impact!of!that!trauma!on!how!the!person!experiences!and!interacts!with!the!world!
! Who!the!person!IS!today!! What!they!NEED!! WHAT!WE!WILL!DO!to!help!the!person!get!what!they!need!
Sample$Biographical$Timeline$
! How!Does!it!Work?!
! Who!Needs!to!Be!Apart!of!the!Team?!
! How!Long!Does!it!Take?!
Trauma$Informed$BioGmeline$Cheat$Sheet$1. Explore!the!individual’s!neo4
natal!experiences:!!!! Was!there!substance!abuse?!! Was!there!domestic!violence?!!
!!2.!!Put!the!age!&!the!dates!on!the!timeline.!!!!!3. Put!Adverse!Childhood!
Experiences!(ACES)!in!red!below!the!line!
4. Put!all!moves!and!placement!changes!(like!school!changes)!in!red.!!
5. Put!other!challenges!in!a!different!color!below!the!line!!
6. Put!respectful!guesses!in!quotes!
7.!!Put!positive!experiences!above!line.!!!!8. Start!the!“I!Am”!part!of!the!chart!
! with!one!feeling!each!person!in!the!room!is!having.!!This!gets!to!the!mirror!neuron!response!and!helps!those!doing!the!timeline!get!their!feelings!out!and!understand!them!as!a!mirror!neuron!response.!!!
! Now!put!yourself!in!their!shoes!&!give!feelings!&!adjectives!&!interests!
!9. Then!move!to!the!“I!Need”!column!!10. Start!interventions!with!the!
Affirmations!for!Rebonding.!!!
11. End!each!timeline!session!with!each!person!stating!one!positive!thing!they!wish!for!the!individual!whose!timeline!is!being!developed.!!This!will!help!with!the!emotions!brought!up!during!the!session.!!!
Natalie develops skill for making people laugh &
entertaining them!
Birth – Age 10: Nomadic Existence = not in same place
more than 5 months.!Sadistic sexual abuse continues.!
N steps in to take abuse for younger siblings when possible!
Family in satanic Cult, ritualized
sadistic sexual abuse!
Exposure to crack, heroine, alcohol, dv!
Neo
nata
l!
Age
6, 1
996!
Age
2, 1
992!
Age
10,
200
0!
Age
7, 1
997!
Age
3, 1
993!
Age
5, 1
995!
Age
1, 1
991!
Age
9, 1
999!
Age
4, 1
994!
Bor
n 19
90!
Age
8, 1
998!
Natalie, birth to 10 years old!
13!
Age 13-14:!
7 placements in 6 months,
extensive self injury,
sexual acting out &
aggression to others!3rd abortion,
ditto!
1st abortion, father transports and pays, no
questions asked!
2nd abortion, ditto!
Natalie first arrested for prostitution!
Oct
ober
200
3!
Age
13,
200
3!
Febr
uary
200
4!
Nov
embe
r 20
03!
Age
13,
200
3!
Sept
embe
r 20
03!
Age
12,
200
2!
Janu
ary
2004!
Aug
ust 2
003!
Age
11,
200
1!
Dec
embe
r 20
03!
Hospitalized for “self” injury, sepsis from untreated UTI
& PID. Parents leave town!
Natalie, 10-14 years old!A
ge 1
0, 2
000!
Hospital reports to CPS & parents
sign VAC!
14!
Age 14-17:!10 residential placements & 2 foster homes only one repeats!Self injury continues!
2nd foster home has her removed for sexual acting out on younger children; 7th and 8th residential placements are
for sex offenders!
Threatens foster family with butcher knife,
does not stab anyone!
DD Services becomes involved!
Age
17,
200
7!
Age
18,
200
8!
Age
16,
200
6!
Age
15,
200
5!
Age
14,
200
4!
Age 16, 7st placement: Natalie diagnosed with
Schizoaffective, ADHD, RAD, Dissociative
Personality Disorder!
Intake report for 10th & final residential placement notes that she “stabbed a
worker at age 15”!
Age 14, 1st placement: Natalie diagnosed with ADHD, RAD, & PDD!
Age 15: Foster home requests her removal after 3 months, documentation
does not state why!
DDS Providers notice her skill for making people laugh & entertaining them, Natalie
reports “I leaned very young they cannot hurt you when they are laughing”!
15!
Age
18,
200
8!
Learns to cook with her staff and is proud to teach her staff how to peal a potato with a butter knife (RF: External Support, Self-Efficacy, Connection with positive adult)!
Writes with behavior specialists a behavior plan that
locks of her knives (RF: Agency, Connection with
positive adult)!
Age 18: Natalie enters supported
living (RF: Agency)!
Natalie starts work at a grocery store with help of job coach and later increase time from 3 to 5 days a week (RF: Agency, Self-Efficacy, Affiliation, Connection
with “positive” adults)!
After!5!months,!she!requests!new!apartment!
and!new!job!16!
Age 19: Job coach fired for inappropriate contact
with those served!
Age 19: Staff introduce her to a DD Sponsored art group (RF: Sense of
Self, Self Worth, Self Efficacy, Affiliation, External Support,
Connection with positive adults)!
Age
19,
200
9!
Introduces team to her alter named
Barbara who is an artist (RF: Sense of
Self, External Supports)!
Natalie starts claiming to have accidents – twisting her ankle,
spraining her wrist, skinned knees. Staff ignore this
“attention seeking” behavior!
Age
18,
200
8!
Introduces team to her alter named Ursula who tells her, “You are a
child of the devil, a waste of flesh. You should have never been born, you need to die!” (Sense of Self)!
Natalie starts trying to choke herself with her hands, pillows and bed sheets, cutting behaviors returns using ends of pencils, broken hair clips, book staples!
At work, she gets a paper cut, a coworker washes it, puts ointment and a band aide on it and there’s no self injury at work from that point forward (RF: Self Worth, External Supports, Connection
with a positive adult)!
17!
Natalie becomes obsessed with being pregnant and
starts lactating!
Supported living nurse contacts psychiatrists about lactating who
immediately stops newest antipsychotic, her obsession with
becoming pregnant gradually stop as medication leave her system (RF:
External Support, Connection with positive adults)!
Age 19, 2009!
Additional antipsychotics are added
to her medications!
18!
Natalie becomes obsessed with being pregnant and
starts lactating!Age 19, 2009!
Natalie meets her new job coach and builds a
connection (RF: External Support, Connection with positive adults)!
Additional antipsychotics are added
to her medications!
Therapists starts using Natalie’s artwork in therapy
(STR: Re-experience & Release)!Sells her first painting
for $100 (RF: Agency, Self Worth, Sense of
Self Efficacy)!
19!
Ages 20-24, 2010-2014!
Agrees to attend a relationship building support group with
boyfriend put on by her therapist (RF: Self Worth,
External Support)!
Fears she is pregnant and wants to die; self injury
returns!
Calls boyfriend when wanting to self injure
(RF: External Support)!
Natalie sells more paintings (RF: Agency, Self Worth, Sense of
Self Efficacy)!
Natalie holds more Art Shows (RF: Agency, Self Worth, Sense of
Self Efficacy)! Tells staff and therapists she felt like she could not
say no to him!Breaks up with
boyfriend saying, “He is a bad influence on me.”!
Natalie has boyfriend (RF: Self Worth, External
Support)!
Becomes intimate with
boyfriend!
20!
Providers notice her skill for
making people laugh &
entertaining them, Natalie
reports “I leaned very young they
cannot hurt you when they are
laughing”!
Natalie develops skill for making people laugh &
entertaining them!
Birth – Age 10: Nomadic Existence = not in same place more than 5 months.!Sadistic sexual abuse
continues.!Stepped into to take abuse for younger
siblings when possible!
Family in satanic Cult,
ritualized sadistic
sexual abuse!
Exposure to crack, heroine, alcohol,
dv!
Neo
nata
l!
Age
6, 1
996!
Age
2, 1
992!
Age
10,
200
0!
Age
7, 1
997!
Age
3, 1
993!
Age
5, 1
995!
Age
1, 1
991!
Age
9, 1
999!
Age
4, 1
994!
Bor
n 19
90!
Age
8, 1
998!
Natalie, birth to 24 years old!
Age 13-14:!7 placements in 6
months, extensive
self injury, sexual
acting out &
aggression to
others!
3rd abortion, ditto!
1st abortion, father
transports and pays, no questions
asked!
2nd abortion, ditto!
Natalie first arrested for
prostitution!
Oct
ober
200
3!
Age
13,
200
3!
Febr
uary
200
4!
Nov
embe
r 20
03!
Age
13,
200
3!
Sept
embe
r 20
03!
Age
12,
200
2!
Janu
ary
2004!
Aug
ust 2
003!
Age
11,
200
1!
Dec
embe
r 20
03!
Hospitalized for “self”
injury, sepsis from untreated
UTI & PID. Parents
leave town!
Age
10,
200
0!Hospital reports to CPS & parents
sign VAC!
Age 14-17:!10 residential placements & 2 foster homes only one repeats!
2nd foster home has her removed for sexual
acting out on younger children; 7th and 8th
residential placements are for sex offenders!
Threatens foster family with
butcher knife, does not stab
anyone!
DD Services becomes involved!
Age
17,
200
7!
Age
18,
200
8!
Age
16,
200
6!
Age
15,
200
5!
Age
14,
200
4!
Age 16, 7st placement: Natalie
diagnosed with Schizoaffective, ADHD, RAD, Dissociative Personality
Disorder!
Intake report for 10th & final residential
placement notes that she “stabbed a
worker at age 15th”!
Age 14, 1st placement:
Natalie diagnosed with ADHD, RAD,
& PDD!
Age 15: Foster home requests her
removal after 3 months,
documentation does not state why!
Age
18,
200
8!
Learns to cook with her staff and is proud to teach her staff how to peal a
potato with a butter knife (RF: External Support, Self-Efficacy, Connection with positive adult)!
Writes with behavior specialists a behavior plan that locks of her knives (RF: Agency,
Connection with positive adult)!
Age 18: Natalie enters
supported living (RF:
Agency)!
At work, she gets a paper cut, a coworker washes it, puts ointment and a bandaide on it and there’s no self injury at work from that point
forward (RF: Self Worth, External Supports, Connection
with a positive adult)!
Natalie starts work at a grocery store with help of job coach and later
increase time from 3 to 5 days a week (RF: Agency, Self-Efficacy, Affiliation, Connection with
“positive” adults)!
Natalie starts claiming to have accidents – twisting her ankle,
spraining her wrist, skinned knees. Staff ignore this attention
seeking behavior!
After!5!months,!she!requests!new!
apartment!and!new!job!
Age 19: Job coach fired for inappropriate contact
with those served!
Age 19: Staff introduce her to a DD Sponsored art group (RF: Sense of
Self, Self Worth, Self Efficacy, Affiliation, External Support,
Connection with positive adults)!
Age
19,
200
9!
Introduces team to her alter named
Barbara who is an artist (RF: Sense of
Self, External Supports)!
Age
18,
200
8!
Introduces team to her alter named Ursula who
tells her, “You are a child of the
devil, a waste of
flesh. You should
have never been born, you need to die!” (Sense of Self)!
Natalie starts trying to choke herself with her hands, pillows and bed sheets, cutting
behaviors return using ends of pencils, broken hair clips, book staples!
Natalie becomes obsessed with being pregnant and starts
lactating!
Supported living nurse contacts
psychiatrists about lactating who
immediately stops newest
antipsychotic, her obsession with
becoming pregnant gradually stop as
medication leave her system (RF:
External Support, Connection with positive adults)!
Age 19, 2009!
Additional antipsychotics are added
to her medications!
Age 19, 2009!
Therapists starts using Natalie’s artwork in therapy
(STR: Re-experience & Release)!
Natalie meets her new job coach and builds a connection (RF: External
Support, Connection with positive adults)!
Sells her first painting for $100 (RF: Agency, Self Worth, Sense of Self
Efficacy)!
Ages 20-24, 2010-2014!
Agrees to attend a relationship building support group with boyfriend put on by her therapist
(RF: Self Worth, External Support)!
Fears she is pregnant and wants to die; self injury returns!
Calls boyfriend when wanting to self injure (RF: External Support)!
Natalie sells more paintings (RF: Agency, Self Worth, Sense of Self Efficacy)!
Natalie holds more Art Shows (RF: Agency, Self Worth, Sense of Self
Efficacy)!
Tells staff and therapists she felt like she could not say no to him!
Natalie has boyfriend (RF: Self Worth, External Support)!
Breaks up with boyfriend saying, “He is a bad influence on me.”!
Becomes intimate with boyfriend!
What$About$Natalie?$
Age Challenges struggles / challenges
specific to age (if known)
Strengths successes specific to
age (if known)
I am State how you feel
related to the timeline. Then
name some adjectives that describe the
individual
I need State what is
needed in connection with
the “I am” statements
Interventions What interventions would help with these needs?
Person responsible
for the intervention (ie: CPST/ therapist /
parent/MD, etc) (if known)
Pregnancy Neonatal exposure to polysubstances
Does%not%use%substances%currently%
% Overwhelmed%%
Structure%that%allows%for%healing%&%growth%
Sensory%Integration%Occupational%Therapy%(OT).%%%
%
%% % Hurt%%
Care% Nurturance,%care%for%injuries%no%matter%how%small%&%soothing%a%sensory%diet.%%
%
% % %Afraid%
Safety% The%Safety%Script%%Rules%connected%with%safety%%Highlighting%when%they%are%safe.%
%
% % %
Confused%Validation% Active%listening%
Focusing%on%the%THEME%NOT%the%content%of%their%stories.%
%
% % % %
Determined%Support%% Opportunities%for%success%
Cheerleaders.%%%
%
23!
What$we$are$learning:$! Defining!roles!!! Communication!from!all!team!members!
! Administrative!! Monthly!team!meetings!with!client!supports!! Trauma4Informed!Supervision!
! Transparency!!! An!overall!objective!to!enhance!the!quality!of!the!person’s!life!
! People!are!individuals!&!the!team!may!not!consider!all!aspects!that!the!client!finds!important!
Finding!Hope!Team!Outcomes!
MUI$Categories$
! Accidental/Suspicious!Death,!! Alleged!Abuse!–!PHYSICAL!! Alleged!Abuse!–!SEXUAL!! Alleged!Abuse!–!VERBAL!! Alleged!Neglect!! Exploitation!(By!Someone!else)!! Failure!To!Report!(provider!failed!to!
report!incident)!! Misappropriation!(provider!
misappropriated!funds!of!the!individual)!
! Non!Accidental!/!Suspicious!Death!! Rights!Code!Violation!! Unapproved!Behavior!Support!!
! Attempted!Suicide!! Law!Enforcement!! Medical!Emergency!! Missing!Individual!! Peer4to4Peer!Acts!(something!they!did!to!someone!else)!
! Prohibited!Sexual!Relations!! Significant!Injury!! Unscheduled!Hospitalization!
MUIs(That(are(Often(OUT(of(the(Individual’s(Control(
MUIs(That(are(Often(WITHIN(the(Individual’s(Control(
HCDDSFMST,$LYSFWAS$and$LPSFDBT$MUI$Change$
MUIs(That(are(Often(OUT(of(the(Individual’s(Control(
MUIs(That(are(Often(WITHIN(the(Individual’s(Control(
0%!10%!20%!30%!40%!50%!60%!70%!80%!90%!100%!
LYS4MST! LPS4DBT! Total!
Graph(#1:(Average(Percent(Decrease(in(Number(of(MUIs(That(are(Often(OUT(of(the(
Individual's(Control(
0%!10%!20%!30%!40%!50%!60%!70%!80%!90%!100%!
LYS4MST! LPS4DBT! Total!
Graph(#2:(Average(Percent(Decrease(in(Number(of(MUIs(That(are(Often(WITHIN(the(
Individual's(Control(
Total$Number$of$MUI$Occurrences$from$Year$Prior$to$Year$One$
0!5!10!15!20!25!30!35!40!45!50!
Total!Occurrences!(10/1/1249/30/13)!
Total!Occurrences!(10/1/1346/30/14)!
#(of(O
ccur
renc
es(
Total!LYS4MST!
Total!LPS4DBT!
Total!
Envision$Retreat$Tracked$Events$
! #!of!Acute!Hospitalizations!! #!of!Residential!Treatment!Placements!! #!of!ER!visits!for!psychiatric/behavioral!concerns!w/o!hospitalization!
! #!of!Police!Involvements!or!Arrests!! #!of!Juvenile!Detention!Placements !!! #!of!School!Suspension/Expulsions !!! #!of!Foster!Care!Placements!
((
Average$Percent$Decrease$in$Total$Number$of$Tracked$Events$Per$Individual$
from$Year$Prior$to$Year$One$
16%(
0%!
20%!
40%!
60%!
80%!
100%!
Envision4Retreat!
Total$Number$of$Tracked$Events$from$Year$Prior$to$Year$One$
60.0!
65.0!
70.0!
75.0!
80.0!
85.0!
Total!#!Baseline!Events!(October!2012!4!September!2013)!
Total!#!!Events!(October!2013!4!June!2014)!
Total(#
(Eve
nts(
“It!is!not!our!responsibility!to!identify!necessarily!the!limits!in!our!patients,!but!rather!for!us!to!identify!the!
limits!in!the!care!that!we!give!them.!!It!is!then,!and!only!then,!when!we!can!go!beyond!them.”!
Albert!Einstein!
Thank$you!$$
Any!questions?!
REFERENCES$! Barol,!B.!(2001).!Learning!from!a!person's!biography:! !An!introduction!to!the!!biographical!timeline!!process.!Positive(Approaches,!3(4),!20429.!
! Focht4New,!G.,!Clements,!P.,!Barol,!B.,!Faulkner,!M.,! !&!Pekala4Service,!K.!(2008).!!Persons!with! !developmental!disabilities!exposed!to! !interpersonal!violence!and!crime:!Strategies!and!guidance!for!assessment.!Perspectives(in(Psychiatric(Care,!44(1),!3413.!
! Gentile,!J.,!&!Gillig,!P.!(Eds.).!(2012).!Psychiatry(of(intellectual(disability:(A(practical(manual.!Oxford:!Wiley4Blackwell.!
References$! Putnam,!F.W.!(2004).!!Experience!Dependent ! !!
!Maturation!0f!Neuronal!Systems.(! Schupp!L.!J.!(2004).!!Assessing(and(Treating(Trauma(and
((PTSD,(Eau!Claire,!Wisconsin:!PESI,!LLC.!! “Trauma”!(2014).!Dictionary.com!Unabriged,!Based!on!
!the!Random!House!Dictionary,!Random!House,!!Inc.!!2014.!
http://dictionary.reference.com/browse/trauma?s=t!!! Walker,!M.!(2005).!Critical!thinking:!Challenging!
!developmental!myths,!stigmas,!and!!stereotypes.!In!D.!!Comstock!(Ed.),(Diversity(and(development:(Critical((contexts(that(shape(our(lives(and(relationships((pp.!!47467).!Belmont,!CA:!!Brooks4Cole.!
!
Contact$Us$!
Rhonda!Craig!!Supervisor,!Multi4System!Team,!!
!Mary!Vicario,!Founder!
Finding!Hope!Consulting,!Cincinnati,[email protected]!
I$want$my$people$to$know$that$they$can$fly!$$$~$Bessie$Coleman$
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