Trauma Informed Care An Overview of Fundamental Concepts A Primary Prevention Tool Created by Huckshorn, Stromberg, LeBel, 2004; Adapted Caldwell 2006

Trauma Informed Trauma Informed Care Care An Overview

of Fundamental Concepts

A Primary Prevention ToolCreated by Huckshorn, Stromberg, LeBel, 2004; Adapted

Caldwell 2006

Creating Violence Free and Coercion Creating Violence Free and Coercion Free Mental Health Treatment Free Mental Health Treatment

Environments for the Reduction of Environments for the Reduction of Seclusion and Restraint:Seclusion and Restraint:

2

Definition of TraumaDefinition of TraumaInformed CareInformed Care

Mental Health Treatment that is Mental Health Treatment that is directed by:directed by:

a thorough understanding of the profound a thorough understanding of the profound neurological, biological, psychological and neurological, biological, psychological and social effects of trauma and violence on the social effects of trauma and violence on the individual and individual and

an appreciation for the high prevalence of an appreciation for the high prevalence of traumatic experiences in persons who traumatic experiences in persons who receive mental health services. receive mental health services. (Jennings, (Jennings, 2004)2004)

3

TraumaTrauma

Trauma is under-reported and Trauma is under-reported and under-diagnosed under-diagnosed (NTAC, 2004)(NTAC, 2004)

Trauma symptoms can include Trauma symptoms can include

inattention, disorganization, inattention, disorganization, depression, problem eating depression, problem eating behaviors and impulsivitybehaviors and impulsivity

4

Types of trauma resulting in Types of trauma resulting in serious and persistent mental serious and persistent mental

health problems:health problems:

Are Are usuallyusually not a “single blow” event not a “single blow” event e.g. rape, natural disastere.g. rape, natural disaster

Are interpersonal in nature: are Are interpersonal in nature: are intentional, prolonged, repeated, intentional, prolonged, repeated, severe severe

Occur in childhood and adolescence Occur in childhood and adolescence and may extend over an individual’s and may extend over an individual’s life spanlife span

((TerrTerr, , 1991; Giller, 19991991; Giller, 1999))

5

““Many providers may Many providers may assume that abuse assume that abuse experiences are additional experiences are additional problems for the person, problems for the person, rather than the central rather than the central problem…”problem…”

((HodasHodas, , 20042004))

6

Prevalence of TraumaPrevalence of TraumaMental Health PopulationMental Health Population

90% of public mental health clients 90% of public mental health clients have been exposedhave been exposed

((Muesar et al, 2004; Muesar et al, 1998Muesar et al, 2004; Muesar et al, 1998))

Most have multiple experiences of Most have multiple experiences of traumatrauma

(Ibid)(Ibid)

34-53% report childhood sexual or 34-53% report childhood sexual or physical abusephysical abuse

((Kessler et al, 1995; MHA NY & NYOMH 1995)Kessler et al, 1995; MHA NY & NYOMH 1995)

43-81% report some type of 43-81% report some type of victimizationvictimization

(Ibid(Ibid))

7

Prevalence of TraumaPrevalence of TraumaMental Health PopulationMental Health Population

97 % of homeless women with SMI have 97 % of homeless women with SMI have experienced severe physical and sexual experienced severe physical and sexual abuse - 87% experience this abuse both abuse - 87% experience this abuse both as child and adultas child and adult

((Goodman et alGoodman et al , , 1997)1997)

Current rates of PTSD in people with SMI Current rates of PTSD in people with SMI range from 29-43%range from 29-43%

((CMHS/HRANECMHS/HRANE, , 1995; Jennings & Ralph, 19971995; Jennings & Ralph, 1997))

Epidemic among population in public Epidemic among population in public mental health systemmental health system

((IbidIbid))

8

Prevalence of TraumaPrevalence of TraumaSubstance Abuse Population Substance Abuse Population

–– Up to two-thirds of men and women in Up to two-thirds of men and women in

SA treatment report childhood abuse & SA treatment report childhood abuse & neglect neglect (CSAT/SAMSHA, 2000)(CSAT/SAMSHA, 2000)

Study of male veterans in SA inpatient unitStudy of male veterans in SA inpatient unit 77% exposed to severe childhood trauma77% exposed to severe childhood trauma 58% history of lifetime PTSD 58% history of lifetime PTSD (Triffleman et al, 1995)(Triffleman et al, 1995)

50% of women in SA treatment have 50% of women in SA treatment have history of rape or incesthistory of rape or incest

(Governor's Commission on Sexual and Domestic Violence, (Governor's Commission on Sexual and Domestic Violence, Commonwealth of Massachusetts, 2006)Commonwealth of Massachusetts, 2006)

9

Incarcerated Women with Mental Incarcerated Women with Mental Health, Substance Abuse and Health, Substance Abuse and

Trauma HistoriesTrauma Histories Correctional Institute for Women, Correctional Institute for Women,

Massachusetts Massachusetts 90% receiving mental health services or 90% receiving mental health services or

substance abuse services have trauma histories substance abuse services have trauma histories ((Dedicated External Female Offender Review, Governor’s Task Force, Dedicated External Female Offender Review, Governor’s Task Force, Commonwealth of Massachusetts, 2005Commonwealth of Massachusetts, 2005))

Correctional Institute for Women, Rhode IslandCorrectional Institute for Women, Rhode Island 40% - Childhood sexual abuse40% - Childhood sexual abuse 55% - Childhood physical abuse55% - Childhood physical abuse 53% - Adult rape53% - Adult rape 63% - Adult physical assault63% - Adult physical assault 34% - Lifetime PTSD34% - Lifetime PTSD (Zlotnick, 1997; Zlotnick, Najavits et (Zlotnick, 1997; Zlotnick, Najavits et

al, 2003)al, 2003)

10

Prevalence of TraumaPrevalence of TraumaChildren and Adolescents -Children and Adolescents -

Juvenile Justice SettingsJuvenile Justice Settings Being abused or neglected as a child Being abused or neglected as a child

increases the likelihood of arrest as juvenile increases the likelihood of arrest as juvenile by 59%by 59% (Widom, CS, 1995)(Widom, CS, 1995)

Rates are up to 8 times higher than Rates are up to 8 times higher than community samples of same-age peerscommunity samples of same-age peers

((Saigh et al, 1999; Saltzman et al, Saigh et al, 1999; Saltzman et al, 2001)2001)

PTSD prevalence data varies widely: 3%-PTSD prevalence data varies widely: 3%-50% in JJ settings 50% in JJ settings (Arroyo, 2001; Garland et al, 2001; (Arroyo, 2001; Garland et al, 2001; Teplin et al, 2002)Teplin et al, 2002)

70% - 92% of incarcerated girls reported 70% - 92% of incarcerated girls reported sexual, physical, or severe emotional abuse sexual, physical, or severe emotional abuse in childhoodin childhood (DOC, 1998; Chesney & Shelden, (DOC, 1998; Chesney & Shelden, 1992)1992)

11

Prevalence of Prevalence of TraumaTrauma

Correctional SettingsCorrectional Settings

Some researchers describe a pathway Some researchers describe a pathway in which exposure to violence and in which exposure to violence and pervasive feelings of not being safe pervasive feelings of not being safe develop into a state of chronic threat develop into a state of chronic threat requiring the youth/adult to use requiring the youth/adult to use physical aggression in order to physical aggression in order to managemanage

(Schwab-Stone et al, 1995)(Schwab-Stone et al, 1995)

12

Prevalence of TraumaPrevalence of TraumaMR/DD PopulationMR/DD Population

Risk of abuse increases by 78% due to Risk of abuse increases by 78% due to exposure to the “disabilities service exposure to the “disabilities service system” alone system” alone (Sobsey & Doe, 1991)(Sobsey & Doe, 1991)

Increased vulnerability to abuse in Increased vulnerability to abuse in institutional settingsinstitutional settings (White, Holland, (White, Holland, Marsland & Oakes, 2003)Marsland & Oakes, 2003)

Sexual abuse incidents are 4 times as Sexual abuse incidents are 4 times as common in institutional settings as in common in institutional settings as in communitycommunity (Blatt & (Blatt & Brown, 1986)*Brown, 1986)*

*Citations from Charlton et al (2004)*Citations from Charlton et al (2004)

13

Prevalence of TraumaPrevalence of TraumaMR/DD PopulationMR/DD Population

Widely believed to be prevalent and under-Widely believed to be prevalent and under-reported due to:reported due to: Difficulty communicating the abuse has Difficulty communicating the abuse has

occurredoccurred Difficulty being believedDifficulty being believed

(Charlton, Kliethermes, Tallant, Taverne, Tishelman, 2004; (Charlton, Kliethermes, Tallant, Taverne, Tishelman, 2004; Beail & Warden, 1995)Beail & Warden, 1995)

Estimates vary widely: 8% to 100%Estimates vary widely: 8% to 100% (Beail & Warden, 1995; Ryan, 2000; Sobsey, (Beail & Warden, 1995; Ryan, 2000; Sobsey,

1994) 1994)

People with developmental disabilities are People with developmental disabilities are exposed to trauma and abuse more exposed to trauma and abuse more frequently than other peoplefrequently than other people

(Ryan, 2005; Sobsey, 1994; Blatt, 1970) (Ryan, 2005; Sobsey, 1994; Blatt, 1970)

14

What does the prevalence What does the prevalence data tell us?data tell us?

The majority of adults and children in The majority of adults and children in psychiatric treatment settings have trauma psychiatric treatment settings have trauma historieshistories

A sizable percentage of people with A sizable percentage of people with substance abuse disorders have traumatic substance abuse disorders have traumatic stress symptoms that interfere with stress symptoms that interfere with achieving or maintaining sobriety achieving or maintaining sobriety

A sizable percentage of adults and children A sizable percentage of adults and children in the prison or juvenile justice system have in the prison or juvenile justice system have trauma historiestrauma histories

Growing body of research on the Growing body of research on the relationship between victimization and later relationship between victimization and later offendingoffending

15

What does the prevalence data What does the prevalence data tell us?tell us?

Children and adults in MR/DD settings Children and adults in MR/DD settings are at particular riskare at particular risk

Many people with trauma histories have Many people with trauma histories have overlapping problems with mental overlapping problems with mental health, substance abuse, and are health, substance abuse, and are victims or perpetrators of crimevictims or perpetrators of crime

Victims of trauma are found Victims of trauma are found across all systems of careacross all systems of care

16

Other Correlates: The Relationship Other Correlates: The Relationship of Childhood Trauma to Adult of Childhood Trauma to Adult

HealthHealth Adverse Childhood Events (ACES) have Adverse Childhood Events (ACES) have

serious health consequences serious health consequences Adoption of health risk behaviors as Adoption of health risk behaviors as

coping mechanismscoping mechanisms eating disorders, smoking, substance eating disorders, smoking, substance

abuse, self harm, sexual promiscuityabuse, self harm, sexual promiscuity Severe medical conditions: heart disease, Severe medical conditions: heart disease,

pulmonary disease, liver disease, STDs, pulmonary disease, liver disease, STDs, GYN cancerGYN cancer

Early DeathEarly Death (Felitti et al, 1998)(Felitti et al, 1998)

17

Trauma and Diagnostic Trauma and Diagnostic IssuesIssues

People with trauma histories may have the People with trauma histories may have the following as primary or co-occurring following as primary or co-occurring disorders: PTSD, Borderline Personality disorders: PTSD, Borderline Personality Disorder, Schizophrenia, Depression and Disorder, Schizophrenia, Depression and other affective disorders, Anxiety other affective disorders, Anxiety Disorders, Eating Disorders, Psychosis, Disorders, Eating Disorders, Psychosis, Dissociative Disorders, Substance Abuse, Dissociative Disorders, Substance Abuse, Somatoform DisordersSomatoform Disorders

Need to be aware of the possibility of Need to be aware of the possibility of misdiagnosismisdiagnosis

((FordFord et al, 2004; Saxe et al, 2003; Felitti et al, et al, 2004; Saxe et al, 2003; Felitti et al, 1998; Mueser et al, 20021998; Mueser et al, 2002))

18

ImplicationsImplications

A majority of adults and A majority of adults and children in inpatient and children in inpatient and residential psychiatric residential psychiatric treatment settings have trauma treatment settings have trauma historieshistories

There is considerable evidence that There is considerable evidence that trauma and abuse are of urgent trauma and abuse are of urgent concernconcern((Cusack et al, 2004; Muesar et al, 1998; Lipschitz et al, 1999; Cusack et al, 2004; Muesar et al, 1998; Lipschitz et al, 1999; NASMHPD, 1998NASMHPD, 1998))

19

Universal Precautions as a Universal Precautions as a Trauma Informed ConceptTrauma Informed Concept

Presume that every person in a Presume that every person in a treatment setting has been treatment setting has been exposed to abuse, violence, exposed to abuse, violence, neglect or other traumatic neglect or other traumatic

experiences.experiences.

20

Impacts of trauma over the Impacts of trauma over the lifespanlifespan

Are neurological, biological, Are neurological, biological, psychological and social in nature. psychological and social in nature. They include:They include:

Changes in brain neurobiologyChanges in brain neurobiology Social, emotional & cognitive impairmentSocial, emotional & cognitive impairment Adoption of health risk behaviors as Adoption of health risk behaviors as

coping mechanisms (eating disorders, coping mechanisms (eating disorders, smoking, substance abuse, self harm, smoking, substance abuse, self harm, sexual promiscuity, violence)sexual promiscuity, violence)

Severe and persistent behavioral health, Severe and persistent behavioral health, health and social problems, early deathhealth and social problems, early death

((Felitti et al, 1998; Herman, 1992Felitti et al, 1998; Herman, 1992))

21

Impact of Trauma on Child Impact of Trauma on Child Development that Informs Development that Informs

Adult BehaviorAdult BehaviorThe ability to form healthy relationships is highly The ability to form healthy relationships is highly

dependent on learned social skillsdependent on learned social skills Children’s social skill learning is directly Children’s social skill learning is directly

related to the characteristics of their related to the characteristics of their environmentsenvironments

Disordered environments=dysfunctional skillsDisordered environments=dysfunctional skills Violence teaches withdrawal, anxiety, Violence teaches withdrawal, anxiety,

distrust, over-reaction and/or aggression as distrust, over-reaction and/or aggression as coping behaviorscoping behaviors

Extreme behaviors are rooted in dysregulated Extreme behaviors are rooted in dysregulated emotional statesemotional states

((NF Commission, 2003; SG Report, 1999; Hodas, 2004; Saxe et NF Commission, 2003; SG Report, 1999; Hodas, 2004; Saxe et al, 2003)al, 2003)

22

Traumatized Children: Traumatized Children: Observations and ExperiencesObservations and Experiences

Appear guarded and anxiousAppear guarded and anxious Are difficult to re-direct, reject supportAre difficult to re-direct, reject support Are highly emotionally reactiveAre highly emotionally reactive Have difficulty “settling” after outburstsHave difficulty “settling” after outbursts Hold onto grievancesHold onto grievances Do not take responsibility for behaviorDo not take responsibility for behavior Make the same mistakes over and over Make the same mistakes over and over

(Hodas, 2004)(Hodas, 2004)

23

Traumatized Children: Traumatized Children: Observations and ExperiencesObservations and Experiences

World is threatening and bewilderingWorld is threatening and bewildering World is punitive, judgmental, World is punitive, judgmental,

humiliating and blaminghumiliating and blaming Control is external, not internalizedControl is external, not internalized People are unpredictable and People are unpredictable and

untrustworthyuntrustworthy Defend themselves above all elseDefend themselves above all else Believe that admitting mistakes is Believe that admitting mistakes is

worse than telling truth worse than telling truth ((HodasHodas, , 20042004))

24

J. Garbarino’s “lost boys” J. Garbarino’s “lost boys” researchresearch

Issues of shame are paramount, Issues of shame are paramount, allowing child to “save face” allowing child to “save face” importantimportant

Violence can be seen as an attempt Violence can be seen as an attempt to achieve justice as child sees itto achieve justice as child sees it

These children cannot afford These children cannot afford empathy as their needs are so great empathy as their needs are so great and overwhelming; tend to de-and overwhelming; tend to de-personalize others personalize others ((HodasHodas, , 20042004))

25

Core Issue: Avoidance of Core Issue: Avoidance of Shame and HumiliationShame and Humiliation

Gilligan, in his prison research Gilligan, in his prison research identified shame/humiliation as core identified shame/humiliation as core element in violence. He says “the element in violence. He says “the basic psychological motive, or cause basic psychological motive, or cause of violent behavior is the wish to ward of violent behavior is the wish to ward off or eliminate the feelings of shame off or eliminate the feelings of shame and humiliation - a feeling that is and humiliation - a feeling that is painful and can even be intolerable- painful and can even be intolerable- and replace it with…a feeling of and replace it with…a feeling of pride” pride”

((HodasHodas, , 20042004))

26

What Happens when Traumatized What Happens when Traumatized Children are Restrained or Children are Restrained or

Secluded?Secluded? Research studies have found that children Research studies have found that children

who were secluded experienced who were secluded experienced vulnerability, neglect, shamevulnerability, neglect, shame

Repeatedly express being reminded of Repeatedly express being reminded of original abuseoriginal abuse

Express feelings of fear, rejection, anger Express feelings of fear, rejection, anger and agitation (verbal and drawings)and agitation (verbal and drawings)

(Wadeson et al, 1976; Martinez, 1999; Mann et al, 1993; Ray et al, (Wadeson et al, 1976; Martinez, 1999; Mann et al, 1993; Ray et al, 1996)1996)

27

What Happens when What Happens when Traumatized Traumatized

Children are Restrained or Children are Restrained or Secluded?Secluded? Felt they were being punishedFelt they were being punished

Confused by staff use of forceConfused by staff use of force

Do not feel protected from harmDo not feel protected from harm

Feelings of bitterness and anger 1 yr Feelings of bitterness and anger 1 yr laterlater

(Wadeson et al, 1976; Martinez, 1999; Mann et al, 1993; Mohr et al, (Wadeson et al, 1976; Martinez, 1999; Mann et al, 1993; Mohr et al, 1998; Ray et al, 1996)1998; Ray et al, 1996)

28

TRAUMA INFORMED TRAUMA INFORMED CARECARE

Organizational Commitment/Trauma Organizational Commitment/Trauma Policy/PhilosophyPolicy/Philosophy

Train/Supervise All Staff in Train/Supervise All Staff in Prevalence, Impact, Organizational Prevalence, Impact, Organizational Treatment Philosophy & Expected Treatment Philosophy & Expected InteractionsInteractions

Universal, Reliable & Universal, Reliable & Developmentally Appropriate Trauma Developmentally Appropriate Trauma AssessmentsAssessments

29


Using/Integrating Assessments to Using/Integrating Assessments to Identify Risk Factors Associated with Identify Risk Factors Associated with Conflict & ViolenceConflict & Violence

Universal Individualized Safety Universal Individualized Safety Planning (integrated with other Planning (integrated with other assessments and fully assessments and fully operationalized in program and in operationalized in program and in community)community)

30


Organizational Culture: Organizational Culture: Physical EnvironmentsPhysical Environments Treatment & Support Environments Treatment & Support Environments

Infused with Recovery & Resiliency Infused with Recovery & Resiliency Focus (e.g., Respect/Kindness/ Focus (e.g., Respect/Kindness/ Collaboration versus Control/ Collaboration versus Control/ Empowerment/Hope)Empowerment/Hope)

Individualized ApproachesIndividualized Approaches Program Practices (e.g., Variety of Program Practices (e.g., Variety of

Activities, Choice, Holistic Offerings)Activities, Choice, Holistic Offerings)

31


Sensory Modulation Sensory Modulation Comfort/Sensory Rooms/Corners/CartsComfort/Sensory Rooms/Corners/Carts A Range of Sensory ApproachesA Range of Sensory Approaches

Use of Trauma Specific Treatment Use of Trauma Specific Treatment ModelsModels

32

Trauma Informed Care Trauma Informed Care Systems Organizational Systems Organizational

CommitmentCommitment Adoption of a trauma informed policy to Adoption of a trauma informed policy to

include:include: commitment to appropriately assess commitment to appropriately assess

traumatrauma avoidance of re-traumatizing practicesavoidance of re-traumatizing practices

Key administrators get on boardKey administrators get on board

Resources available for system modifications Resources available for system modifications and performance improvement processesand performance improvement processes

Education of staff is prioritizedEducation of staff is prioritized ((Fallot & HarrisFallot & Harris, , 2002; Cook et al, 20022002; Cook et al, 2002))

33

Trauma Informed Care Trauma Informed Care Systems Organizational Systems Organizational

CommitmentCommitment

Staff can access expert trauma Staff can access expert trauma consultationconsultation

Staff can access trauma-specific Staff can access trauma-specific treatment if indicatedtreatment if indicated

((Fallot & HarrisFallot & Harris, , 2002; Cook et al, 20022002; Cook et al, 2002))

34

Trauma Informed Care Trauma Informed Care SystemsSystems

Organizational CommitmentOrganizational Commitment Assessment data informs treatment Assessment data informs treatment

planning in daily clinical workplanning in daily clinical work

Advance directives, safety plans and de-Advance directives, safety plans and de-escalation preferences are communicated escalation preferences are communicated and usedand used

Power & Control are minimized by Power & Control are minimized by attending constantly to unit cultureattending constantly to unit culture

((Fallot & HarrisFallot & Harris, , 2002; Cook et al, 20022002; Cook et al, 2002))

35

Trauma AssessmentTrauma Assessment

PurposePurpose

Used to identify past or current trauma, Used to identify past or current trauma, violence, abuse, and assess related violence, abuse, and assess related sequelaesequelae

Provides context for current symptoms Provides context for current symptoms and guides clinical approaches and and guides clinical approaches and recovery progressrecovery progress

Informs the treatment culture to Informs the treatment culture to minimize potential for re-traumatizationminimize potential for re-traumatization

((Cook et alCook et al, , 2002; Fallot & Harris, 2002; Maine BDS, 20002002; Fallot & Harris, 2002; Maine BDS, 2000))

36


Trauma measurement tools increase Trauma measurement tools increase diagnostic reliabilitydiagnostic reliability Post-Traumatic Diagnostic Scale for Post-Traumatic Diagnostic Scale for

adults adults ((Foa et al, Foa et al,

19971997))

Child PTSD Symptom Scale Child PTSD Symptom Scale ((Foa et al, 2001Foa et al, 2001))

Trauma Symptom Checklist for Children Trauma Symptom Checklist for Children ((BriereBriere, , 19951995))

Child Stress Disorders Checklist, CSDC Child Stress Disorders Checklist, CSDC ((Saxe et alSaxe et al, , 20032003))

37

Trauma Trauma Assessments/InformationAssessments/Information

Bessel van der Kolk:Bessel van der Kolk:http://www.traumacenter.org/assesshttp://www.traumacenter.org/assessment.htmlment.html

The Child Trauma Institute: The Child Trauma Institute: http://http://www.childtrauma.com/ax.htmlwww.childtrauma.com/ax.html

Child Trauma Academy (Bruce Child Trauma Academy (Bruce Perry): Perry): http://www.childtrauma.orghttp://www.childtrauma.org

38


Continued follow-up, preferably Continued follow-up, preferably with same provider/clinician is with same provider/clinician is suggested, due to sensitivity of suggested, due to sensitivity of issue.issue.

Must be integrated with safety Must be integrated with safety planning.planning.

((IbidIbid))

39


Should minimally include:Should minimally include:

TypeType:: sexual, physical, emotional abuse sexual, physical, emotional abuse or neglect, exposure to disasteror neglect, exposure to disaster

AgeAge:: when the abuse occurred when the abuse occurred

WhoWho: : perpetrated the abuseperpetrated the abuse Assessment of such symptoms as: Assessment of such symptoms as:

dissociation, flashbacks, hyper-vigilance, dissociation, flashbacks, hyper-vigilance, numbness, self-injury, anxiety, numbness, self-injury, anxiety, depression, poor school performance, depression, poor school performance, conduct problems, eating problems, etc.conduct problems, eating problems, etc. ((IbidIbid))

40

Trauma AssessmentTrauma Assessment Results and “Results and “positive responsespositive responses” must be addressed in ” must be addressed in

treatment planning or assessment is uselesstreatment planning or assessment is useless Interview is conducted upon intake or shortly afterInterview is conducted upon intake or shortly after Importance of therapeutic engagement during interview Importance of therapeutic engagement during interview

cannot be over emphasizedcannot be over emphasized For children, assessment through play and behavior For children, assessment through play and behavior

observationsobservations((IbidIbid))

41


Other MH factors to assessOther MH factors to assess History of S/R; involuntary IM medication History of S/R; involuntary IM medication

experiencesexperiences Individual experiences in inpatient settings Individual experiences in inpatient settings

– fear, dissociation, anger, powerlessness– fear, dissociation, anger, powerlessness Homelessness, addiction, domestic violenceHomelessness, addiction, domestic violence What happened when disclosed?What happened when disclosed? More loss? More loss?

Validation and protection? Validation and protection? Interest in working on a safety plan (see Interest in working on a safety plan (see

tools module)tools module)

42

Immediate Concerns that Immediate Concerns that Require InterventionRequire Intervention

Continued trauma experiences including Continued trauma experiences including domestic or partner violencedomestic or partner violence

Lack of safety in home, community or Lack of safety in home, community or treatment setting treatment setting

Presence of other external stressors that Presence of other external stressors that create hypervigilance, anxiety create hypervigilance, anxiety ((HodasHodas, , 20042004))

Need to collaborate with/report to other Need to collaborate with/report to other agencies (child welfare, elder abuse, agencies (child welfare, elder abuse, domestic violence)domestic violence)

43



Infused with Recovery & Resiliency Infused with Recovery & Resiliency Focus (e.g., Respect / Kindness / Focus (e.g., Respect / Kindness / Collaboration versus Control/ Collaboration versus Control/ Empowerment/Hope)Empowerment/Hope)



44

Biggest Barrier: Biggest Barrier: Transforming Transforming

Organizational CultureOrganizational CultureOperationalizing TIC by:Operationalizing TIC by: Truly using strength-based Truly using strength-based

approachesapproaches Moving from Control to Moving from Control to

Collaboration (e.g., level systems; Collaboration (e.g., level systems; consequence focus; rule enforcers; consequence focus; rule enforcers; individual strategies, such as individual strategies, such as music/late bed time/late night food music/late bed time/late night food seen as reinforcers)seen as reinforcers)

45

Trauma-Specific Treatment Trauma-Specific Treatment ModelsModels

Examples: Examples: Seeking SafetySeeking Safety ((Najavits, 2003Najavits, 2003))

Trauma treatment for adults and Trauma treatment for adults and adolescents with substance abuse adolescents with substance abuse disordersdisorders

Coping skills focused on behavior, Coping skills focused on behavior, thinking, relationshipsthinking, relationships

25 skills areas including: compassion, 25 skills areas including: compassion, asking for help, setting boundaries in asking for help, setting boundaries in relationships, grounding, self-carerelationships, grounding, self-care

Positive results in 4 outcome trialsPositive results in 4 outcome trials

46

Trauma-Specific Treatment Trauma-Specific Treatment ModelsModels

Examples: Examples: Sanctuary ModelSanctuary Model (Bloom, 2002)(Bloom, 2002)

Applied to two inpatient servicesApplied to two inpatient services Democratic, non-violent community Democratic, non-violent community

environmentenvironment Safety, affect management, grieving, Safety, affect management, grieving,

emancipationemancipation Applicable to children, adolescents and Applicable to children, adolescents and

adultsadults

47

Trauma-Specific Treatment Trauma-Specific Treatment Models Examples:Models Examples:

Trauma Focused Cognitive Trauma Focused Cognitive Behavior TherapyBehavior Therapy ((Cohen, Deblinger, Mannarino, & Cohen, Deblinger, Mannarino, & Steer,Steer, 20042004))

For children and non-offending parentFor children and non-offending parent 12 sessions with joint sessions with parent12 sessions with joint sessions with parent

Stress managementStress managementPsychoeducationPsychoeducationCognitive coping (Trauma Narrative)Cognitive coping (Trauma Narrative)Cognitive ProcessingCognitive ProcessingBehavior ManagementBehavior Management

48


Trauma Systems Therapy (TST)Trauma Systems Therapy (TST) (Saxe, Ellis, Kaplow, Grant, Tames, Boston University Medical Center, (Saxe, Ellis, Kaplow, Grant, Tames, Boston University Medical Center,

2004)2004)

Two Overarching Themes: Two Overarching Themes: Traumatized child has difficulty self-regulatingTraumatized child has difficulty self-regulatingSocial environment unable to help child Social environment unable to help child

regulateregulate FocusFocus

Intervening in the environment itself: home or Intervening in the environment itself: home or community basedcommunity based

Developmentally appropriateDevelopmentally appropriateEmotional regulation skillsEmotional regulation skills

49


Trauma Adaptive Recovery Group Trauma Adaptive Recovery Group Education and TherapyEducation and Therapy (Juvenile (Juvenile Justice) Justice) (Ford, Chapman, Pearson, Hawke, Albert, University (Ford, Chapman, Pearson, Hawke, Albert, University of Connecticut Health Center, 2005of Connecticut Health Center, 2005))

SOS Skills (Gain Control of Brain’s Alarm) Slow Down: One Thought/Feeling/Goal

at-a-time Orient: Shift Attention to the Immediate

Moment – Breathe, Notice your Body, Observe the Environment

Self Check: Stress Thermometer (1-10), Personal Control Level (10-1), Personal Safety Plan (1-10)

50

Critical Components of Critical Components of CBTCBT

Cognitive Behavioral Therapy (CBT) in Cognitive Behavioral Therapy (CBT) in various forms is regarded as either various forms is regarded as either “promising” or “evidenced based” for “promising” or “evidenced based” for traumatized individualstraumatized individuals

Includes education and goal setting Includes education and goal setting Coping skill development including Coping skill development including

recognition of triggersrecognition of triggers Termination and relapse preventionTermination and relapse prevention Booster sessionsBooster sessions (Hodas, 2004)(Hodas, 2004)

51

Core Elements in Most Core Elements in Most Effective Treatment Effective Treatment

ProgramsPrograms Memory identification, processing and Memory identification, processing and

regulationregulation Anxiety managementAnxiety management Identification and alteration of Identification and alteration of

maladaptive cognitionsmaladaptive cognitions Interpersonal communication and social Interpersonal communication and social

problem solvingproblem solving (Ibid)(Ibid)

Direct Intervention in the Direct Intervention in the home/communityhome/community

(Saxe et al., 2004)(Saxe et al., 2004)

Role of Medication Role of Medication ((Hodas, 2004)Hodas, 2004)

52


Organizational Trauma Policy / PhilosophyOrganizational Trauma Policy / Philosophy Train / Supervise All Staff in Prevalence, Train / Supervise All Staff in Prevalence,

Impact, Organizational Treatment Impact, Organizational Treatment Philosophy & Expected InteractionsPhilosophy & Expected Interactions

Universal, Reliable & Developmentally Universal, Reliable & Developmentally Appropriate Trauma AssessmentsAppropriate Trauma Assessments

Universal Individualized Safety Planning Universal Individualized Safety Planning (integrated with other assessments and (integrated with other assessments and fully operationalized in program and in fully operationalized in program and in community)community)

53



Infused with Recovery & Resiliency Infused with Recovery & Resiliency Focus (e.g., Respect / Kindness / Focus (e.g., Respect / Kindness / Collaboration versus Control/ Collaboration versus Control/ Empowerment/Hope)Empowerment/Hope)



54


Sensory Modulation Sensory Modulation Comfort/Sensory Rooms/Corners/CartsComfort/Sensory Rooms/Corners/Carts A Range of Sensory ApproachesA Range of Sensory Approaches

Use of Trauma Specific Treatment Use of Trauma Specific Treatment ModelsModels

55

““I have learned two lessons in my life: I have learned two lessons in my life: first, there are no sufficient literary, first, there are no sufficient literary, psychological, or historical answers psychological, or historical answers to human tragedy, only moral ones. to human tragedy, only moral ones. Second, just as despair can come to Second, just as despair can come to one another only from other human one another only from other human beings, hope, too, can be given to beings, hope, too, can be given to one only by other human beings.”one only by other human beings.”

Elie WieselElie Wiesel

Author and Holocaust SurvivorAuthor and Holocaust Survivor

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Contact InformationContact InformationBeth CaldwellBeth CaldwellCaldwell Management AssociatesCaldwell Management Associates413-644-9319413-644-9319bethcaldwell@[email protected]

Kevin Huckshorn / Sarah CallahanKevin Huckshorn / Sarah CallahanNational Technical Assistance Center National Technical Assistance Center

(NTAC)(NTAC)NASMHPDNASMHPD703-739-9333, ext 140 & 141703-739-9333, ext 140 & [email protected]@nasmhpd.org or or

[email protected]@nasmhpd.org

Documents

Trauma Informed Care An Overview of Fundamental Concepts A Primary Prevention Tool Created by Huckshorn, Stromberg, LeBel, 2004; Adapted Caldwell 2006