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9/28/17
San Francisco Department of Public Health, Trauma Informed System Initiative. 1
TransformingStressandTrauma:Fostering Wellness and Resilience
HealingOrganiza6ons:TraumaTransformed
10/11/17
AdaptedfromUCSFHealthyEnvironmentsandResponsetoTraumainSchools(HEARTS)Curriculumby
JoyceDorado,Ph.D.Director,UCSFHEARTS
ChildandAdolescentServicesUCSF-SanFranciscoGeneralHospital
LynnDolce,MFT
Director,FosterCareMentalHealthChildrenYouthandFamiliesSystemofCare
TransformingStress&Traumawasadaptedfrom:
UCSFHealthyEnvironmentsandResponsetoTraumainSchools(HEARTScurriculum;JoyceDorado&LynnDolce)
bytheTISfoundingworkgroupmembers:KenEpstein,LynnDolce,JoyceDorado,BrianaLoomis,Norman
Aleman,Kay6eSpeziale,andMichaelMarcin.
Pleaseciteas:
SanFranciscoDepartmentofPublicHealth,TraumaInformedSystemIni6a6ve.(2014).Transformingstressandtrauma.[organiza6onaltrainingcurriculum]SanFrancisco,CA:Author.
Directcorrespondenceto:
KenEpstein,PhD,[email protected]
10/11/17
9/28/17
San Francisco Department of Public Health, Trauma Informed System Initiative. 2
GoalsforTodayTodevelopasharedunderstandingandlanguageaboutstressandtrauma
Toprovideguidingprinciplesandprac6caltoolstosupportyouatwork
GoalsofTrauma-InformedSystemsIni6a6ve
Tocreateatrauma-informedpublichealthsystemthatfosterswellnessandresilienceforeveryoneinthesystem
10/11/17
OutlineforToday• Overview• UnderstandingStressandTrauma• CulturalHumility• Break• SafetyandStability• CompassionandDependability• Collabora6onandEmpowerment• Break• ResilienceandRecovery• CommitmenttoChangeAc6vity
10/11/17
Resources
Wecanberesilientandhealfromchronicstressandtrauma.
WesupportTrauma-InformedCare.
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San Francisco Department of Public Health, Trauma Informed System Initiative. 3
WhyIsaTrauma-InformedApproachImportanttoMe?
Becausestressandtraumaimpactallofus
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ThesePeopleMadeitThroughandChangedtheWorld
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San Francisco Department of Public Health, Trauma Informed System Initiative. 4
Reflec6onCommunityMee6ngStructure
– Whatisyourname?
– Howareyoufeeling?(Onewordinyourbubble)
– Whatisonegoalyouhaveforthistraining?
– Nameonesuccessyouhavehadthisweek
– Reflectonyourownreac6ontothevideo
(fromSanctuaryModel,Bloometal.,2013)10/11/17
Let’sTalkAboutStress
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HowStressAffectsOurJobPerformance:TheYerkes-DodsonLaw
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San Francisco Department of Public Health, Trauma Informed System Initiative. 5
StressandTraumaArePublicHealthIssues
• Stresslinkedto6leadingcausesofdeath– Heartdisease,cancer,lungailments,accidents,cirrhosisoftheliver,andsuicide
• Traumaimpactsmorethanjusttheindividual– Rippleeffecttoothers
• Somecommuni6esdispropor6onatelyaffected:– Bigotry+UrbanPoverty+Trauma=Toxic
• Intergenera6onaltransmissionoftrauma• Systemic,preventa6veapproachneeded
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Vignele
10/11/17
WhatiswrongwithAnthony?
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WhatiswrongwithVanessa?
10/11/17
ShimYourPerspec6vefrom
"Whatiswrongwithyou?"to
"Whathashappenedtoyou?"
(fromWisconsinDept.ofHealthServiceswww.dhs.wisconsin.gov/6c)
Providescontext,fosterscompassion,helpsustoseestrengthsinfaceofadversity
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Resilience&Recovery
Collabora6on&Empowerment
CulturalHumility&Responsiveness
Safety&Stability
Compassion&Dependability
UnderstandingTrauma&Stress
System&Service
Perspec6ves
Neurobiology&
Development
Trauma-InformedPrinciplesforPromo8ngWellnessandResilience
System&Service
FormalPolicies&Administra6ve
Supports
Accountability
Inter-agencyStructures&Prac6ces
ServiceDelivery&
Prac6ce
Perspec6ves
Clients
Family
Community
Staff
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San Francisco Department of Public Health, Trauma Informed System Initiative. 7
Trauma-InformedSystem:CoreGuidingPrinciple
UnderstandingTraumaandStress
“Learningaboutthepsychobiologyofstress,toxicstress,andtraumaislibera6ngforpeople.Itgivesusexplanatoryreasonsforsomeofthepuzzlingbehaviorsweengageinandthefeelingsthatcancometodominateus.”(Bloom,2013,p.48)
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WhathashappenedtoAnthony?
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WhathashappenedtoVanessa?
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San Francisco Department of Public Health, Trauma Informed System Initiative. 8
Trauma=Event,Experience,&Effect
Overwhelmsbrainandbody
Helplesstoescape
Dis-integra8on
(Herman, 1997; Van der Kolk, 2005; DSM-5; SAMHSA; Siegel, 2012; Bloom, 2013)
Actualorextremethreatofharm
“Fight,flightorfreeze”
Las6ngadverseeffects
Dysregula8on
Event
Experience
Effect
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ComplexTrauma
Repe66veharm,neglect,orabandonmentbypeoplewedependuponcancompromisedevelopment
(CourtoisandFord,2009)
BuildingaTrauma-Informed,HealingSystemStructure:
• Safety&Stability• Compassion&
Dependability• Collabora6on&
Empowerment• Resilience&Recovery
Furniture:Trauma-InformedPrac6ces
Founda8on:• Trauma
Understanding• CulturalHumility&
Responsiveness10/11/17
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San Francisco Department of Public Health, Trauma Informed System Initiative. 9
Stretch
Adapta6onstoComplexTrauma
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WeSharetheSameNeurobiology
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San Francisco Department of Public Health, Trauma Informed System Initiative. 10
Accelerator BrakesSympathetic Parasympathetic
dilates pupils
relaxes bronchi
accelerates heart beat
inhibits digestion
contracts vessels
contracts pupils
constricts bronchi
slows heart beat
stimulates digestion
dilates vessels
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Challenge Threat
Perceivedresources
Perceivedresources
Perceivedstressor
Perceivedstressor
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HPAAxisAc6vatedinResponsetoThreat
Pituitary
Hypothalamus
ImmuneSystem
AdrenalCortex Cor8sol
Cor8sol
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ChronicStressCauses“WearandTear”ontheBody
• Medicalillnesses• Immunesystemsuppression• Inflammatorydiseases• Obesity
• Adverseeffectsonbrainandcogni6vefunc6oning
• Fromstressorsthatarechronic,uncontrollable,experiencedwithoutsupportfromcaringothers
• Canresultfromstressorslikebigotry,poverty,chronichunger
(Bloom,2013;McEwen,2000);10/11/17
Neuronsthatfiretogetherwiretogether
(Hebb’sRule)
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Trauma“WearsaGroove”intheBrain
“TheFearSong”10/11/17
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SurvivalMode:Fight/Flight/FreezeFrontallobe(prefrontalcortex)goesoffline
Limbicsystem/midandlowerbrainfunc6onstakeover
ThinkingBrain(PrefrontalCortex) Survival/
Emo8on Brain(LimbicSystem)
(Ford, 2009, Van der Kolk)
ThinkingBrainandSurvivalBrain• ThinkingBrain=RiderMakesinformed,ra6onaldecisions
• SurvivalBrain=HorseProtec6veins6nctsbasedonfeelings
• Whentriggered,theriderfallsoffthehorse
(VanderKolk)(Ford,2009)
Dysregula6on• Dysregula6onisdifficultycontrollingtheinfluenceofstressarousalonhowwethink,feel,behaveandinteractwithothers
• Thiscanhappenwhenweare“triggered”intoSurvivalBrain
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San Francisco Department of Public Health, Trauma Informed System Initiative. 13
KeyTool:GetYourRideronYourHorse
• Aggrava6ngbehavioris“acauseforapause”• Pauseandtakeabreath• Askyourself
– “Whathashappenedtoyou?”– “Whatishappeninghere?”– “Whatistheneedbehindthisbehavior?”– “HowcanIrespondtothisneed?”
10/11/17
Heisbull
ying
me
Whatishappeninghere?Mysonisgoingtodie
Sheis
abando
ningu
s
I’mnever
goingto
catchupHe’s
dangero
usNomaler
whatIdoit
’s
notenough
Anthony Vanessa
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SystemicLevel:ChronicStressandTraumaCanLeadtoDis-organiza6on
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ATrauma-InformedSystemTakesCareofthe
Caregivers
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Transforming Our Organizations
10/11/17
Resilience&Recovery
Collabora6on&Empowerment
CulturalHumility&Responsiveness
Safety&Stability
Compassion&Dependability
UnderstandingTrauma&Stress
System&Service
Perspec6ves
Neurobiology&
Development
Trauma-InformedPrinciplesforPromo8ngWellnessandResilience
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Trauma-InformedSystem:CoreGuidingPrinciple
CulturalHumilityandResponsivenessWecomefromdiversesocial
andculturalgroupsthatmayexperienceandreacttotraumadifferently.Whenweareopentounderstandingthesedifferencesandrespondtothemsensi6velywemakeeachotherfeelunderstoodandwellnessisenhanced.
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CulturalHumility
• Lifelonglearningandcri6calself-reflec6on• Recognizingandchangingpowerimbalances• Developingins6tu6onalaccountability
(Tervalon&Murray-Garcia,1998)
“Morethanaconcept,CulturalHumilityisaprocessofcommunalreflec6on
toanalyzetherootcausesofsufferingandcreateabroader,more
inclusiveviewoftheworld.”
10/11/17
ShimYourPerspec6ve
from"Whatiswrong?"
to
"Whathashappened?"
(fromWisconsinDept.ofHealthServiceswww.dhs.wisconsin.gov/6c)
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What’sWrong:APublicHealthExample
HealthDispari8esandTrauma
Race Place Health
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HealthDispari6es:WhatHappened?
Race Place Health
InsidiousTraumaHistoricalTraumaIns6tu6onalRacism
CommunityViolence
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InsidiousTrauma
“likedropsofacidfallingonastone”
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ContextMaTers
Racism
Oppression
Inequity
Sexism
Classism
Xenophobia
TraumaSynergis8cTrauma
Homophobia
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HistoricalTrauma
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Opportunity*Intergenera6onal
poverty*Disinvestment
Place*Unsafepublic
spaces*Deterioratedenvironments*Unhealthyproducts
People*Fragmented
socialrela6onships*Destruc6vesocial
norms
UnderstandingCommunityLevelTrauma(Pinderhughes et al.
Prevention Institute Report, 2015)
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Opportunity*Economic
empowerment*Qualityeduca6on*Restora6vejus6ce
Place*Saferpublic
spaces*Investinparks,
housing,transporta6on
*Availablehealthyproducts
People*Rebuild
rela6onships*Strengthenhealthysocial
norms
Promo6ngCommunityResilience(Pinderhughes et al.
Prevention Institute Report, 2015)
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Star6ngwiththeSelf
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AnneFadiman,2008
CreateaSharedCulture
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StressOmenInterfereswithCrea6ngSharedCulture
(adaptedfrompresenta6onbyGhosh-Ippen,2012)
10/11/17
CulturalHumilityExercise• Race• Religion• Ethnicity• Na6onality• Appearance• Bodystructure• Physicalability
• Gender• Age• Occupa6on• Sexualorienta6on• Educa6on• Class
• Primarylanguage• Family
constella6on• Immigra6on
status
AdaptedbyMelanieTervalonfrom:PinderhughesEB:UnderstandingEthnicity,RaceandPower:TheKeytoEfficacyinClinicalPrac6ce.NewYork:TheFreePress,1989,p.25
AwarenessandAccountabilityWeallhaveimplicitbiasesTakethetest:Implicit.com
MustbecomeawareofourbiasesNeedtopreventourbiasesfromharmingothers
10/11/17
Resilience&Recovery
Collabora6on&Empowerment
CulturalHumility&Responsiveness
Safety&Stability
Compassion&Dependability
UnderstandingTrauma&Stress
System&Service
Perspec6ves
Neurobiology&
Development
Trauma-InformedPrinciplesforPromo8ngWellnessandResilience
10/11/17
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Trauma-InformedSystem:CoreGuidingPrincipleSafetyandStability
Traumaunpredictablyviolatesourphysical,social,andemo6onalsafetyresul6nginasenseofthreatandneedtomanagerisks.Increasingstabilityinourdailylivesandhavingthesecoresafetyneedsmetcanminimizeourstressreac6onsandallowustofocusourresourcesonwellness.10/11/17
KeyTool:EstablishSafety
PhysicalsafetyProtec6onfromharmReduc6onofunnecessarytriggers
SocialsafetyBuildposi6veworkingrela6onshipsthatcanprovidesupportandcalmingin6mesofstress
Emo6onalsafetyBuildskillsinmanagingemo6ons
StabilityRou6nes,predictabilityandconsistency
Emo6onalSafety:Emo6onRegula6on
Capacityto:• Iden6fyemo6ons
• Expressemo6ons
• Modulateemo6ons(NCTSN,2003)
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AvoidRe-escala6on:WhereAreYouintheCycle?
Client’s Cycle
(AdaptedfromSFGHSafetyManagementandResponseTechniques(SMART)Training)10/11/17
ToolsforStressReliefatWork• Physicalmovement
– Stretching– Goingforawalk
• Tac6legrounding– Lo6on– Stressballs
• Drinkwater• Breathingexercises(bellybreathing)
• Sleepwell,eathealthily,exercise
Keystowellnessbreak:• Onethingata6me• Enjoyable• Physicalac6vity• Breathedeeply
10/11/17
BellyBreathingSlowbreathoutthroughmouth
Emptychest,thenbelly(emptybellyairallthewayout)
SlowbreathinthroughnoseFillbelly,thenchestwithair
• Exhaleac6vates“brakes”inbody• Re-setsbrainandbody• Allowsbodytometabolizestressarousal
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Re-visi6ngtheVignele
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Vignele:ApplyingTrauma-InformedPrinciples
UnderstandingTrauma&StressCulturalHumility&Responsiveness
SafetyandStabilityApplyyourknowledge
aboutstress,trauma,andtrauma-informedprinciplestothevigneletoimprovetheoutcome.
10/11/17
Resilience&Recovery
Collabora6on&Empowerment
CulturalHumility&Responsiveness
Safety&Stability
Compassion&Dependability
UnderstandingTrauma&Stress
System&Service
Perspec6ves
Neurobiology&
Development
Trauma-InformedPrinciplesforPromo8ngWellnessandResilience
10/11/17
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San Francisco Department of Public Health, Trauma Informed System Initiative. 23
Trauma-InformedSystem:CoreGuidingPrinciple
CompassionandDependabilityTraumaisoverwhelmingandcanleaveusfeelingisolatedorbetrayed,whichmaymakeitdifficulttotrustothersandreceivesupport.However,whenweexperiencecompassionateanddependablerela6onships,wereestablishtrus6ngconnec6onswithothersthatfostermutualwellness. 10/11/17
Rela6onshipsAreCentraltoHealing
• Needconnec6onasmuchasfood(Harlow,1958)
• Healthyrela6onshipsinvolvealunement– Beingsensi6ve,responsive,andinharmonywiththefeelingsandneedsofourselvesandofothers
• Alunedinterac6onshelpustofeelsafeandcalmdownwhenwearestressedout
HumansAreHard-wiredforConnec6on
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Co-Regula6on
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Co-Regula6on
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ComplexTraumaInterfereswithCo-Regula6on
• Ifchild’scaregiverissourceoftraumaorunavailabletoprovideco-regula6on,canderaildevelopmentofhealthyemo6onregula6onskills
• Thisaffectsrela6onshipsinadulthood
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ReframingRiskBehaviorsTensionreduc8onbehaviors– Drugsandalcohol– Risk-takingbehavior– Self-injuriousbehavior– Compulsivestealing– Aggression– Problema6csexualbehaviors(whereanyconnec6onfeelsbelerthanabandonmentandisola6on)
(fromtrainingonIntegratedTreatmentforComplexTraumabyJohnBriere,2009)
10/11/17
Rela6onshipDifficul6es
Whenhumanshaveexperiencedcomplextrauma:• Overlyclingy/dependent• Pushothersaway• Don’tknowhowtomakeuseofhelpful
others(includingproviders)Workingwithtraumacanpullforintenseemo6onsinstaff:
• Vicarious/Secondarytrauma
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San Francisco Department of Public Health, Trauma Informed System Initiative. 26
Whatpushesyourbulons?
Outofpropor6onreac6ons
Confusionbetween“thereandthen”and“hereandnow”
10/11/17
Rela6onshipBuildingTool:Connect,thenRe-Direct(Siegel)
• Partnership“Let’sworktogether”• Empathy“Thatsoundsfrustra6ng”• Apology“I’msorrythathappened”• Respect“Youhavegonethroughalot”• Legi6ma6on“Itmakessensethatyoufeelthisway”
• Support“Let’sseewhatwecando”(AmericanAcademyonCommunica6oninHealth)
10/11/17
YouCanMakeaDifference“BigI”=Interven6ons“Lillei”=interac6ons
(Ghosh-Ippen,2013)
CAPPD
calm,aluned,present,predictable&don’tescalate(fromMulEpleConnecEons,Philadelphiatraining)
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San Francisco Department of Public Health, Trauma Informed System Initiative. 27
Resilience&Recovery
Collabora6on&Empowerment
CulturalHumility&Responsiveness
Safety&Stability
Compassion&Dependability
UnderstandingTrauma&Stress
System&Service
Perspec6ves
Neurobiology&
Development
Trauma-InformedPrinciplesforPromo8ngWellnessandResilience
10/11/17
Trauma-InformedSystem:CoreGuidingPrinciple
Collabora6onandEmpowermentTraumainvolvesalossofpowerandcontrolthatmakesusfeelhelpless.However,whenwearepreparedforandgivenrealopportuni6estomakechoicesforourselvesandourcare,wefeelempoweredandcanpromoteourownwellnessandthewellnessofothers. 10/11/17
TraumaHelplessness
Disempowerment
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MovingThroughTrauma
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Empowerment:Promo6ngaSenseofAgency
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Collabora6onTool:FosterVoiceandChoice
ARCC– Ask– Respond– Clarify– Confirm
• “Doesthisworkforyou?”
(AdaptedfromAmericanAcademyonCommunica6oninHealth)
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Resilience&Recovery
Collabora6on&Empowerment
CulturalHumility&Responsiveness
Safety&Stability
Compassion&Dependability
UnderstandingTrauma&Stress
System&Service
Perspec6ves
Neurobiology&
Development
Trauma-InformedPrinciplesforPromo8ngWellnessandResilience
10/11/17
Trauma-InformedSystem:CoreGuidingPrincipleResilienceandRecovery
Traumacanhavealong-las6ngandbroadimpactonourlivesthatmaycreateafeelingofhopelessness.Yet,whenwefocusonourstrengthsandclearstepswecantaketowardwellnesswearemorelikelytoberesilientandrecover.
10/11/17
Science-BasedHabitsofHappinessPeoplewhoprac6ce
mindfulnesshavestrongerimmunesystems,aremorelikelytobehappyandenjoygreaterlifesa6sfac6on,andarelesslikelytofeelanxious
orhos6le.Beingkindtoothersmakesusfeelgood.
Altruis6cactslightupthesamepleasurecentersinthebrainasfoodandsex.
(greatergood.berkeley.edu/ar6cle/item/how_to_be_happy_fine_print)
Regularexerciseincreasesself-esteem,reducesanxietyandstress,andmaywellbethemost
effec6veinstanthappinessboosterofall.10/11/17
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ResilienceTool:Cul6va6ngGra6tude
• KeepaGra6tudeJournal• List5thingsthatyouaregratefulforonceperweek
• Countyourblessingsonceaday(Emmons,2010)
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Prac6cingGra6tudeIncreasesWell-Being
• Physical•Strongerimmunesystems•Lowerbloodpressure
• Psychological•Morealert,alive,andawake•Moreop6mismandhappiness
• Social•Morehelpful,generous,andcompassionate•Lesslonelyandisolated
(Emmons,2010)
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TheGoodnessofGra6tude
• Gra6tudeallowsustocelebratethepresent• Gra6tudeblockstoxic,nega6veemo6ons• Gratefulpeoplearemorestressresistant
(Emmons,2010)
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San Francisco Department of Public Health, Trauma Informed System Initiative. 31
Whatareyougratefulfor?
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ApplyingTrauma-InformedPrinciplesResilienceandRecovery
• Whatstepswillyoutaketotake
careofyourself?• Whataresomethingsyoucandofor/witheachother?
• Whatdoyouneedfromyourworkplacetoenhancewell-beingforall?
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Resilience&Recovery
Collabora6on&Empowerment
CulturalHumility&Responsiveness
Safety&Stability
Compassion&Dependability
UnderstandingTrauma&Stress
System&Service
Perspec6ves
Neurobiology&
Development
Trauma-InformedPrinciplesforPromo8ngWellnessandResilience
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CommitmenttoChange
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ATrauma-InformedSystemisn’tatraining,oranidea,orabuzzword–it’s
anexperience.
It’syourexperience.
Applyingtheprinciplesinourworklivesisgoodforus,goodforourcolleagues,andgoodforthe
peopleweserve.
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Howcanwemakeadifferenceinyourworklife?
Big,policylevelsystemchangesarenecessarybutnotsufficient…
Smallindividualchangesthatyouimplementhaveabig
impactonyou
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Whataboutyou?Whatareyoursmallsteps?
• Ideasfromtodaythatinspiredyou• Principlesthatareimportanttoyou• Examplesthatresonatedwithyourlife“Iwillmeetwithmysupervisortodiscussasafetyconcernandgetsupportresolvingit.”
Inthenextmonth,let’salltakeonesmallsteptowardexperiencingatraumainformedworklife.
10/11/17
Over6,000SFDPHemployeeshavecommiledtoaC2Cproject!
“It was difficult at first. But as I put it into
practice, I felt a sense of relief because it became easier to
incorporate it in my attitude and thinking.”
“It makes coming to work worthwhile.”
70%aresuccessful
74%willcon6nue
thechange
“one of the best things to ever
happen to me”“empowering”
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San Francisco Department of Public Health, Trauma Informed System Initiative. 34
YourCommitment2ChangeProject
10/11/17
Share&Inspire
Ifyoufeelcomfortable,shareyourideaswithyourgroup.
Helpinspire,plan,andsupporteachother’sC2Cprojects.
ThenturninyourC2CPlan!
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Inordertowrapuptoday,weneedyouto:
1. Completetheconfiden6alC2Chandoutduetoday• TherewillbeagiXcarddrawingforcomple8ngafollow-upsurvey!
2. Keepthe sheet,turninthewhitesheet
3. CompleteandturnintheblueTrainingEvalua6onform
Thanks!Ourtrainerwillcloseusout…
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San Francisco Department of Public Health, Trauma Informed System Initiative. 35
TransformingTrauma
Atrauma-informedsystemunderstandshowchronicstressandtraumaaffectshumanbeings
ANDcreatessafeandsuppor6vecareenvironmentsthatfosterstrengthand
resiliency,sothateveryoneinthesystemcandevelop,growandthrive10/11/17
Closing:SoupBowlBreathing
10/11/17
