Understanding Trauma and

Why We Must Address It

Understanding Trauma and

Why We Must Address It

New York State Office of Mental HealthMarch 2010

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Acknowledgement

The New York State Office of Mental Health wishes to acknowledge the contributions of the National Association of State Mental Health Program Directors (NASMHPD) and its Office of Technical Assistance (formerly NTAC) for many of the following slides.

Objectives

Define Trauma and Trauma-Informed Care

Review Prevalence and Implications Compare Trauma-Informed and

Trauma-Insensitive Systems Identify Core Elements of

Organizational Commitment

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Trauma-Informed Care:Competency Assessment

Does More Harm Lacks Capacity Trauma-Neutral Trauma-Sensitive Trauma-Informed Trauma-Proficient

What is Trauma?

NASMHPD (2006) The experience of violence and victimization

including sexual abuse, physical abuse, severe neglect, loss, domestic violence and/or the witnessing of violence, terrorism or disaster

DSM IV-TR (APA 2000) - Person’s response involves intense fear,

horror, and helplessness - Extreme stress that overwhelms ability to cope

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Trauma Includes:

Sexual & physical abuse, neglect, emotional abuse, abandonment, poverty, sudden and traumatic loss

A severe one time, or repeated event

Actions perpetrated by someone known

Acts that betray trust

Prevalence of TraumaMental Health Population-US

90% of public mental health clients have been exposed to trauma (Muesar et al., 2004. Muesar et al., 1998)

51-98% of public health clients have been exposed to trauma (Goodman et al., 1997. Muesar et al.,1998)

Most have multiple experiences with trauma (Muesar et al., 2004. Muesar et al., 1998)

97 % of homeless women with SMI have experienced severe physical & sexual abuse, and 87% experience this abuse both in childhood and adulthood (Goodman et al., 1997)

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Prevalence of TraumaChild Mental Health/Youth Detention-US

Canadian study of 187 adolescents reported 42% had PTSD

American study of 100 adolescent inpatients: 93% had trauma histories and 32% had PTSD

70-90% of incarcerated girls - sexual, physical and emotional abuse

(Doc. 1998. Chesney & Sheldon, 1991)

What Does This Tell Us?

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

A sizeable percentage of people with substance abuse disorders have traumatic stress symptoms that interfere with maintaining stability

A sizable percentage of adult and children in the prison or juvenile justice systems have trauma histories(Hodas 2004, Cusack et al., Mueser et al., Lipschitz et al, 1999, NASMHPD 1998)

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Therefore…

We need to presume that the clients we serve have a history of traumatic stress and exercise “universal precautions” by creating systems of care that are Trauma-Informed

(Hodas, 2005)

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Learned Response

Brain chemistry/development affected by trauma

Immediate “fight or flight” response

Heightened sense of fear/danger

Typical Trauma-related Symptoms

Dissociation Flashbacks Nightmares Hyper-vigilance Terror Anxiety Pejorative auditory

hallucinations Difficulty w/problem

solving

Numbness Depression Substance abuse Self-injury Eating problems Poor judgment and

continued cycle of victimization

Aggression

Triggers and Flashbacks

Triggers are sights, sounds, smells, and touches, that remind the person of the trauma.

Flashbacks are recurring memories, feelings, and thoughts.

Traumatic stress brings the past to the present.

Post Traumatic Stress Disorder (PTSD) Defined:

Post Traumatic Stress Disorder (PTSD) Defined:

The development of characteristic symptoms, following exposure to a traumatic stressor involving direct personal experience or witnessing another person’s experience of:

• Actual or threatened death• Actual or threatened serious injury• Threat to physical integrity

Critical Trauma Correlates

Adverse Childhood Events (ACE’s) have serious health consequences

Adoption of health risk behaviors as coping mechanisms (eating disorders, smoking, substance abuse, self-harm, sexual promiscuity)

Severe medical conditions: heart disease, pulmonary disease, liver disease, STDs, GYN cancer

Early Death 15

Adverse Childhood Experiences

Recurrent and severe physical abuse Recurrent and severe emotional abuse Sexual abuse Growing up in household with:

• Alcohol or drug user• Member being imprisoned• Mentally ill, chronically depressed, or institutionalized

member• Mother being treated violently• Both biological parents absent• Emotional or physical abuse

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Trauma-Informed Care

Recognition of prevalence of trauma Assessment and treatment for

trauma Focus on what happened to you vs.

what is wrong with you Informed by current research Recognition that coercive

environments are re-traumatizing

Trauma-Informed Care Recipient is center of his/her own

treatment Recipient and family are empowered Wellness and self management are the

goal Transparent and open to outside parties Power/control are minimized Staff are trained and understand function

of behavior

Trauma-Informed CareTrauma-Informed Care

The focus is on collaboration - Not engaging in interactions that are

demeaning, disrespectful, dominating, coercive, or controlling

Responding to disruptive behaviors with empathy, active listening skills and questions that engage the recipient in finding solutions

Trauma-Informed Language

Person centered Respectful - get permission to use

first name Conscious of tone of voice and noise

level Body language Helpful and hopeful Objective, neutral language

Trauma-Informed Environment

Respectful interaction Opportunities for individual

“space” and activities Welcoming settings Person-centered signage

Lack of education on trauma

Over-diagnosis of schizophrenia, singular addictions, bipolar and conduct disorders

Rule enforcement/compliance focus

Behavior seen as intentionally provocative

Labeling: “manipulative, needy, attention-seeking”

Non-Trauma-Informed

Problems Associated witha Controlling Culture

Problems Associated witha Controlling Culture

Focus is on staff, not the recipient

Addressing a problem is built around staff and program convenience

Rules become more important as staff knowledge about their origin erodes

Compliance and containment are mistaken as actual learning of new skills by the recipient and/or real improvement

Problems Associated witha Controlling Culture

Minor violations often lead to control struggles

Fosters a belief that privileges (rights) must be earned

Reinforces a need to control the recipient

Poorly trained staff who bully recipients into compliance are not identified or disciplined

These same staff may be rewarded for maintaining safety or creating a quiet shift

Exercise

Rephrase the following using Trauma-Informed language:

“You need to get out of bed now!”“You need to get in line for lunch”“No, you can’t go back to your room”

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What Happens when Traumatized Consumers are Restrained or Secluded?

Research studies have found that children who were secluded:

Experienced vulnerability, neglect, shame

Repeatedly express being reminded of original abuse

Express feelings of fear, rejection, anger and agitation (verbally and in drawings) (Wadeson et al., 1976; Martinez, 1999; Mann et al., 1993; Ray et al., 1996)

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What Happens when Traumatized Consumers are Restrained or Secluded?

Felt they were being punished

Were confused by staff use of force

Do not feel protected from harm

Report feelings of bitterness and anger one year later(Wadeson et al., 1976; Martinez, 1999; Mann et al. 1993; Mohr, 1999; Ray et al., 1996)

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Trauma Assessment

Purpose

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

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

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

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

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Trauma Assessment Should minimally include:

• Type: sexual, physical, or emotional abuse or neglect, exposure to disaster

• Age: when the abuse occurred

• Who: perpetrated the abuse

• Assessment of such symptoms as: dissociation, flashbacks, hyper-vigilance, numbness, self-injury, anxiety, depression, poor school performance, conduct problems, eating problems, etc.(Ibid)

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Trauma Assessment Results and “positive responses” must be

addressed in treatment planning or assessment is useless

Interview is conducted upon intake or shortly after

Importance of therapeutic engagement during interview cannot be over-emphasized

For children, assessment through play and behavior observations(Ibid)

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Core Elements in the Most Effective Treatment Programs

Memory identification, processing and regulation

Anxiety management Identification and alteration of maladaptive

cognitions Interpersonal communication and social

problem-solving Direct intervention in the home/community Appropriate use of medication

(Hodas, 2004)

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Organizational Commitment to Trauma-Informed Care

Adoption of a trauma-informed policy to include: Commitment to appropriately assess trauma Avoidance of re-traumatizing practices Key administrators on board Resources available for system modifications

and performance improvement processes Education of staff prioritized

(Fallot & Harris, 2002; Cook et al., 2002)

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Organizational Commitment to Trauma-Informed Care

Unit staff can access expert trauma consultation

Unit staff can access trauma-specific treatment if indicated

(Fallot & Harris, 2002; Cook et al., 2002)

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Organizational Commitment to Trauma Informed Care

Assessment data informs treatment planning in daily clinical work

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

Power & Control are minimized by attending constantly to unit culture

(Fallot & Harris, 2002; Cook et al., 2002)

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In Summary...

Appreciate high prevalence rates Understand the characteristics of trauma-

informed care and how this differs from care that is not informed by trauma

Assess histories and symptoms of trauma and link to treatment plans/crisis plans

Provide support and skill development