TIC: Trauma-Informed Care Trauma-Informed Connection Scott Webb, LCSW Trauma-Informed Care Coordinator April 29, 2016 Division of Mental Health and Substance Abuse Services 1

Learning Objectives 123 Understand the significance of the adverse childhood experiences study as a public health concern Understand what trauma-informed care is, what it looks like, and how it is different from the medical model 2 Define and be able to identify the different types of trauma and its prevalence in society Division of Mental Health and Substance Abuse Services

3 Think about going into an unfamiliar environment be it a meeting, social event, etc. What helps you feel welcome and connected?

Trauma Defined Division of Mental Health and Substance Abuse Services 4

Why Trauma? Why Now? Consumer activism Prevalence Science Effective services Hope Division of Mental Health and Substance Abuse Services 5

Why Trauma-Informed Care? “We are a traumatized field working with traumatized clients, sending them to a traumatized recovery community.” Dan Griffin Division of Mental Health and Substance Abuse Services 6

Self Care and Compassion Breathe Provide self empathy Use positive self-talk reframing (I am safe) Feel feet on floor Count to ten Use fidgets Doodle Division of Mental Health and Substance Abuse Services 7

Trauma and Post-Traumatic Stress Disorder (PTSD) “…the peace of mind you deserve in the present is help hostage by the terror of your past.” Lily Burana (2009, p. 227) Division of Mental Health and Substance Abuse Services 8

Trauma Touches All of Us Trauma is universal Trauma happens regardless of: o Age o Culture o Gender o Class Trauma is a life-shaping event Division of Mental Health and Substance Abuse Services 9

Trauma Defined It is extreme stress (threat to life, bodily integrity, or sanity) It is subjective It often results in feelings of vulnerability, helplessness, and fear Division of Mental Health and Substance Abuse Services 10

Trauma Defined (cont’d) It often interferes with relationships It interferes with connection It affects the fundamental beliefs about themselves and others It causes one to question their place in the world It disrupts the nervous system Division of Mental Health and Substance Abuse Services 11

Types of Trauma Acute Complex Historical Sanctuary Vicarious Division of Mental Health and Substance Abuse Services 12

Types of Trauma Acute Complex Historical Sanctuary Vicarious Division of Mental Health and Substance Abuse Services 13

Complex Trauma “Our labels don’t describe the complex interrelated physical, psychological, social, and moral impacts of trauma…and they rarely help us know what to do to help.” Sandra Bloom, M.D. Division of Mental Health and Substance Abuse Services 14

“Being traumatized means continuing to organize your life as if the trauma were still going on— unchanged.” Bessel Van Der Kolk, M.D. Division of Mental Health and Substance Abuse Services 15

Trauma’s Prevalence Fifty-six percent of the general population report at least one traumatic event in their life (Kessler, 1996) Ninety percent of behavioral health consumers have been exposed to a traumatic event; most have multiple exposures (Muesar, 1998) Division of Mental Health and Substance Abuse Services 16

Trauma’s Prevalence (cont’d) Eighty-three percent of females and thirty-two percent of males with developmental disabilities have experienced sexual assault. Of those, fifty percent had been assaulted ten or more times (Hand, 1986) Division of Mental Health and Substance Abuse Services 17

Trauma’s Prevalence (cont’d) Eighty-three percent of females and thirty-two percent of males with developmental disabilities have experienced sexual assault. Of those, fifty percent had been assaulted ten or more times (Hand, 1986) Division of Mental Health and Substance Abuse Services 18

Trauma’s Prevalence (cont’d) Ninety-seven percent of homeless women with mental health issues experienced severe physical and/or sexual abuse (Goodman, et al., 1997) Seventy-five to ninety-three percent of youth entering the juvenile justice system are estimated to have experienced some degree of traumatic victimization (Healing Invisible Wounds, Justice Policy Institute) Division of Mental Health and Substance Abuse Services 19

Division of Mental Health and Substance Abuse Services 20 Adults who experience trauma may self medicate Self medication may also increase risk for further abuse and traumatic experiences (Review of possible order effects by Simpson and Miller, 2002)

Prevalence of Trauma and Substance Abuse A majority of women in substance abuse treatment have a history of physical and sexual abuse A significant number of clients in inpatient treatment also have subclinical traumatic stress symptoms or PTSD Division of Mental Health and Substance Abuse Services 21

Mediating and Exacerbating Factors Person (Age, developmental stage, past experiences, strengths, cultural beliefs) Environment (support systems, access to safety, resources) Event (Severity and chronicity, interpersonal vs. act of nature, intentional or accidental) Division of Mental Health and Substance Abuse Services 22

Adverse Childhood Experiences (ACE) Division of Mental Health and Substance Abuse Services 23

Early Relationships In these relationships we learn to: o Regulate emotions o Develop trust in others o Freely explore our environment o Understand ourselves and others o Begin to establish a worldview Division of Mental Health and Substance Abuse Services 24

ACE Studies National ACE Study Wisconsin ACE Study Division of Mental Health and Substance Abuse Services 25

Household with o Substance abuse o Mental illness o Separation or divorce o Domestic violence o Imprisoned household member Division of Mental Health and Substance Abuse Services 26 Abuse o Psychological (by parents) o Physical (by parents) o Sexual (by anyone) o Physical neglect o Emotional neglect

ACE Score Equals Trauma Dose The number of individual types of adverse childhood experiences were summed: ACE Score Prevalence 032% 126% 216% 310% 4 or more16% Division of Mental Health and Substance Abuse Services 27

National ACE Study Findings Division of Mental Health and Substance Abuse Services 28

National ACE Study Findings Division of Mental Health and Substance Abuse Services 29

2011 Wisconsin ACE Study Findings Division of Mental Health and Substance Abuse Services 30

2011 Wisconsin ACE Study Findings Division of Mental Health and Substance Abuse Services 31

Division of Mental Health and Substance Abuse Services 32

Division of Mental Health and Substance Abuse Services 33

Division of Mental Health and Substance Abuse Services 34 Fight: Resist Flight: Run away Freeze: Stay still Trauma and Disrupted Neurodevelopment

Division of Mental Health and Substance Abuse Services 35

Division of Mental Health and Substance Abuse Services 36

Reminders or Triggers Lack of control Threats or feeling threatened or attacked Observing threats or assaults Isolation Interacting with authority figures Lack of information Division of Mental Health and Substance Abuse Services 37

Reminders or Triggers (cont’d) Lack of privacy Removal of clothing Being watched Loud noises Darkness Intrusive or personal questions Division of Mental Health and Substance Abuse Services 38

Reminders or Triggers (cont’d) Being locked in room Being ignored Condescending looks Separation or loss Transitions Feelings of vulnerability and rejection Division of Mental Health and Substance Abuse Services 39

Inward Expressions o Withdrawal o Substance use or abuse o Perfectionistic o Violence to self o Spacing out Division of Mental Health and Substance Abuse Services 40 Outward Expressions o Anger or defiance o Violence toward others o Truancy o Criminal acts o Perfectionism Explaining not Excusing Behaviors

Developmental Trauma o Basic mistrust of others o Belief that the world is unsafe o Negative self worth o Fear and pessimism o Hopeless and powerless Division of Mental Health and Substance Abuse Services 41 Typical Development o Belief in a predictable world o Positive self worth o Hopeful and optimistic o Empowered Trauma’s Impact on Worldview

Trauma Worldview No place is safe Other people are unsafe and cannot be trusted My own actions, thoughts, and feelings are unsafe I expect crisis, danger, and loss I have no worth and no abilities Division of Mental Health and Substance Abuse Services 42

Trauma-Informed Care (TIC) Division of Mental Health and Substance Abuse Services 43

Do No Harm “We need to presume 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) Division of Mental Health and Substance Abuse Services 44

Trauma-Informed Care What it is: o A principle-based culture change process o It focuses how trauma may affect an individual’s life and their response to behavioral health services What it is not: o An intervention to address PTSD o A “flavor of the day” approach Division of Mental Health and Substance Abuse Services 45

Trauma-Informed Care Division of Mental Health and Substance Abuse Services 46 “What’s wrong with you?” “What happened to you?” “What’s right with you?”

Trauma-Informed Care A TIC approach incorporates three key elements: o Realizing the prevalence of trauma o Recognizing how trauma affects all individuals involved with the program, organization, or system including its own workforce o Responding by putting this knowledge into practice Division of Mental Health and Substance Abuse Services 47

Division of Mental Health and Substance Abuse Services 48 Healing happens in relationships Understand the prevalence and impact of trauma Promote safety Earn trust Embrace diversity Provide holistic care Respect human rights Pursue the person’s strengths, choice, and autonomy Share power Communicate with compassion

Five Primary TIC Principles Safety Trustworthiness Choice Collaboration Empowerment (Fallot and Harris, 2006) Division of Mental Health and Substance Abuse Services 49

Trauma-Informed “What happened to you?” o Symptoms seen as adaptations to trauma o Wellness plans, stress reduction are among many tools used to recover o Healing happens in healthy relationships -- connection Division of Mental Health and Substance Abuse Services 50 Traditional “What’s wrong with you?” o Key focus is symptom reduction o Rules, directives, tired systems to maintain order o Therapy viewed as primary often sole healing approach Comparison

Re-traumatization A situation, attitude, interaction, or environment that replicates the events or dynamics of the original trauma that triggers overwhelming feelings Can be obvious or not so obvious Usually unintentional It is always hurtful Division of Mental Health and Substance Abuse Services 51

Re-traumatization within the System Female with second operating while intoxicated charge is placed in an all male psychoeducation group (Female was sexually assaulted at age 15) Receptionist meets new client with a scowl and provides instructions in a short, curt manner Clinic has poor soundproofing in “private” offices Division of Mental Health and Substance Abuse Services 52

What TIC Looks Like Avoid forcing eye contact Be aware of your proximity Avoid asking too many questions Pace client meetings by offering breaks Draw upon past success Ask before touching or hugging Provide choice when possible Ask about client’s goals and priorities Division of Mental Health and Substance Abuse Services 53

What TIC Looks Like During emotional times ask “How can I support you right now?” When the trauma story overwhelms or leaves you speechless, be willing to sit in supportive silence Division of Mental Health and Substance Abuse Services 54

What TIC Looks Like Provide clear information about when, where, and by whom services will be provided Be prepared to repeat information many times; repetition is commonly needed when consumers are working with an overwhelmed nervous system Division of Mental Health and Substance Abuse Services 55

Trauma-Informed Addiction Treatment Trauma-informed addictions services are also integrated services : the symptoms of trauma and the consequences of addiction are addressed within a single system and by a single model of care (Harris and Fallot, 2001) Division of Mental Health and Substance Abuse Services 56

Public Health Interventions Exposure to adversity is a public health issue Three levels of intervention: primary, secondary, and tertiary  Primary intervention is aimed at everyone  Secondary interventions are aimed at people who are at risk for a problem  Tertiary interventions focus on trying to help people who already have whatever problems it is we are defining (Sandra Bloom, M.D. 2015) Division of Mental Health and Substance Abuse Services 57

Public Health Interventions Primary intervention: Trauma- informed care because everyone should be informed Secondary intervention: Trauma- responsive services because we can assess who is at risk Tertiary intervention: Trauma- centered services that are used to help traumatized people heal (Sandra Bloom, M.D. 2015) Division of Mental Health and Substance Abuse Services 58

Going Forward with TIC Based on what we know, it is time for all our sectors to take a lifespan approach As a society, we have a moral responsibility to do something with the knowledge we now have that most of the suffering brought about in the world today is preventable (Sandra Bloom, M.D. 2015) Division of Mental Health and Substance Abuse Services 59

TIC and Organizational Culture Change Need leadership buy-in and ongoing support TIC Champions (core implementation team) Meaningful consumer involvement Trauma-sensitive human resource practices Trauma-sensitive environment Trauma sensitive strategies and tools Work toward fidelity Division of Mental Health and Substance Abuse Services 60

Final Thought “Every life is a piece of art, put together with all means available.” Pierre Janet Division of Mental Health and Substance Abuse Services 61

Contact Information Scott A Webb, LCSW Trauma-Informed Care Coordinator Division of Mental Health and Substance Abuse Services Division of Mental Health and Substance Abuse Services 62