Providing Trauma-Informed Care to the Homeless and MH Populations Kristina Bechtel, CSW WRIC CCS Social Worker La Crosse County Integrated Support and Recovery Services

Today’s topic can be a heavy one so please practice self-care: Breathe Doodle Take a Break

Trauma Defined Trauma is an emotional response to a terrible event like an accident, rape, or natural disaster. - American Psychological Association Psychological trauma may set in after a distressing or life-threatening event - Psychology Today A very difficult or unpleasant experience that causes someone to have mental or emotional problems usually for a long time - Merriam-Webster

Trauma is different for everyone Trauma Defined Cont'd... Trauma is different for everyone Often results in feelings of vulnerability, helplessness, and fear Often interferes with relationships

Who can be affected by Trauma? Trauma is universal Trauma happens regardless of: age culture gender class Trauma is a life-shaping event

Types of Trauma Acute Complex Historical Sanctuary Vicarious Psychological

Acute and Complex Trauma Acute Trauma Complex Trauma Adult onset Single incident Adequate child development Not linked to mental health disorder Early onset Multiple incidents Extended over time Highly invasive Interpersonal Highly stigmatizing Vulnerable

Complex Trauma Cont'd Dysregulation: Emotional: Difficulty managing feelings; low frustration tolerance; shame; chronic emptiness Cognitive: Catastrophizing; concrete thinking; memory impairments Interpersonal: Difficulty assessing social cues; difficulty seeking attention in appropriate ways; challenges in seeing another's point of view; difficulty in maintaining relationships Behavioral: Impulsive; suicidal; self-injurous, chemical use/dependency; trauma re-enactment

Complex Trauma Cont'd How it may get diagnosed: Post-Traumatic Stress Disorder (PTSD) Borderline Personality Disorder Attention Deficit Hyperactivity Disorder (ADHD) Oppositional Defiant Disorder (ODD)

Historical Trauma Collective and cumulative emotional psychological wounding across generations, emanating from massive group trauma Generates survivor guilt, depression, low self-esteem, psychic numbing, anger, and other physical symptoms

Sanctuary Trauma The overt and covert traumatic events that occur in settings that are socially sanctioned as safe: Medical, mental health and substance use disorder services Corrections Foster care Home School and boarding schools Places or worship

Vicarious Trauma The experience of learning about another person's trauma and experiencing trauma-related distress as a result of this exposure

Psychological Trauma Violence (physical, verbal, witnessing) Home Personal Relationships Workplace School Maltreatment or abuse Emotional or spiritual Verbal or physical Exploitation Sexual Financial Psychological Abrupt change in health, employment, living situation over which people have no control

Trauma and Substance Use Adults who experience trauma may self medicate; self medication may also increase risk for further abuse and traumatic experiences.

Adverse Childhood Experiences (ACE) Early Relationships Relationships are developed through the emotional bond between the child and caregiver. It is through this relationship that we learn to: Regulate emotions Develop trust in others Freely explore our environment Understand ourselves and others Understand that we can impact the world around us Begin to establish a worldview

ACE Abuse Psychological (by parents) Physical (by parents) Sexual (by anyone) Physical neglect Emotional neglect Household with: Substance use Mental illness Separation or divorce Domestic violence Imprisoned household member

Traumatic Experiences Why the ACE is important… Traumatic Experiences Coping Skills Consequence/Barrier Shame Make connections To understand why barriers were made in the first place changes the perception that actions are simply behavioral You can remove the barrier but if you don’t address the why, the barriers will continue to manifest

There is nothing we can do about what happened to them, but there is absolutely something we can do to make sure the cycle of trauma does not continue when they are with us!

Reminders or Triggers Lack of control Threats or feeling threatened or attacked Observing threats or assaults Isolation Interacting with authority figures Lack of information Being told what to do Lack of privacy Removal of clothing (medical exams) Sensory experiences (smells, sounds, touch, taste, body position) Being touched Being watched Loud noises Darkness Intrusive or personal questions Being locked in a room Being ignored Condescending looks/Tone of voice Transitions or disruptions in routine Feelings of vulnerability and rejection Sensory overload (crowded spaces, loud sounds, powerful smells) A trigger can be a person, place, thing, event time, date, smell, or texture

Explaining not Excusing Behaviors Outward Expressions Anger or defiance Violence towards others Truancy Criminal acts Perfectionism Inward Expressions Withdrawal Substance use Violence to self Spacing out Acknowledge the trauma but focus on the resiliency…

"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)

Taking it one step further…practice universal trauma informed care! It’s important to treat everyone you come into contact with as though they could have experienced a trauma Relatives Friends Coworkers Cashier Coffee Barista Etc…

Trauma-Informed Approach What it is: A principal-based culture change process It focuses how trauma may affect an individual's life and their response to behavioral health services What it is not: An intervention to address PTSD (not therapy) A "flavor of the day" approach

“What’s wrong with you?” “What happened to you?” Even if the story does not come out, work with people as if there is a story there. “What’s right with you?”

A trauma informed approach incorporates four key elements: Realizing the prevalence of trauma Recognizing how trauma affects all individuals, including its own workforce Responding by putting this knowledge into practice Resisting re-traumatization

What does a trauma informed approach look like? Avoid forcing eye contact Be aware of your proximity Avoid asking too many questions Pay attention to your tone of voice Pace client meetings by offering breaks Draw upon past successes Ask before touching or hugging Provide choice when possible Ask about a client's goals or priorities 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 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 clients are working with an overwhelmed nervous system

Safety Best practices: Avoid re-traumatization Consider the role of shame in both addiction and trauma Avoid judgements Be genuine as you build rapport Ask open-ended questions Convey experience, strength, and hope

Trauma Informed Service is not something you "do" to people, it is how you approach people.

Any others Unacceptable terms when speaking to or about clients: Crazy Cray-Cray Cuckoo B***chy Nutty Nutso Nut Job Frequent Flyer Off his/her rocker Piece of work Batty Bat S**t Psycho Any others

Questions? Kristina Bechtel La Crosse County – ISRS 300 4th St. N La Crosse, WI 54601 kbechtel@lacrossecounty.org 608-789-8582

Tonier Cain: Trauma Across the Lifespan https://www.youtube.com/watch?time_continue=3&v=SXCt0qO6LDY