Robert W. Glover, Ph.D. Executive Director Creating Trauma Informed Systems of Care for Human Service Settings Brian Sims, M.D. NASMHPD Consultant National Association of State Mental Health Program Directors

Represents the $36.7 Billion Public Mental Health System serving 6.4 million people annually in all 50 states, 4 territories, and the District of Columbia. An affiliation with the approximately 220 State Psychiatric Hospitals: Serve 200,000 people per year and 50,000 people served at any point in time.

Vision: Mental health is universally perceived as essential to overall health and well-being with services that are available, accessible, and of high quality. Mission: NASMHPD serves as the national representative and advocate for state mental health agencies and their directors and supports effective stewardship of state mental health systems. NASMHPD informs its members on current and emerging public policy issues, educates on research findings and best practices, provides consultation and technical assistance, collaborates with key stakeholders, and facilitates state to state sharing. Priorities for NASMHPD Transforming Mental Health

Introduction Some of the Presentation Content May Describe Traumatic Experiences Some of the Presentation Content May Describe Traumatic Experiences –Please Take Care of Yourself Word Choice Translation Word Choice Translation –Examples: “Consumer” versus “User”; “Provider” versus “Caregiver” Consumer Voice – “In Their Own Words” Consumer Voice – “In Their Own Words” 4

Content Introduction I.What is Trauma and Why Must We Address It? (Bob Glover) II. Understanding the Bio-Psychosocial Impact of Trauma (Brian Sims) III.Trauma Sensitive Tools (Bob Glover and Brian Sims) IV.DVD – “Healing Neen” (Bob Glover – Introduction) V. Peer Panel and Next Steps 8

Creating Trauma Informed Systems of Care for Human Service Settings I. What is Trauma and Why Must We Address It?

Seclusion and Restraint - “In Their Own Words”

What is Trauma? Definition (NASMHPD, 2006) Definition (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 disasters DSM IV-TR (APA, 2000) DSM IV-TR (APA, 2000) –Person’s response involves intense fear, horror and helplessness –Extreme stress that overwhelms the person’s capacity to cope 13

14 Types of trauma resulting in serious and persistent mental health problems: Are usually not a “single blow” event e.g. rape, natural disaster Are usually not a “single blow” event e.g. rape, natural disaster Are interpersonal in nature: intentional, prolonged, repeated, severe Are interpersonal in nature: intentional, prolonged, repeated, severe Occur in childhood and adolescence and may extend over an individual’s life span Occur in childhood and adolescence and may extend over an individual’s life span (Terr, 1991; Giller, 1999)

Definition of Trauma Informed Care Mental Health Treatment that incorporates: Mental Health Treatment that incorporates: –An appreciation for the high prevalence of traumatic experiences in persons who receive mental health services –A thorough understanding of the profound neurological, biological, psychological and social effects of trauma and violence on the individual (Jennings, 2004) 15

Prevalence of Trauma Mental Health Population – United States 90% of public mental health clients have been exposed to trauma (Mueser et al., 2004, Mueser et al., 1998) Most have multiple experiences of trauma (Mueser et al., 2004, Mueser et al., 1998) 97% of homeless women with SMI have experienced severe physical & sexual abuse – 87% experience this abuse both in childhood and adulthood (Goodman et al., 1997) 16 Anna Jennings

Prevalence of Trauma Child Mental Health/Youth Detention Population - U.S. American study of 100 adolescent inpatients; 93% had trauma histories and 32% had PTSD American study of 100 adolescent inpatients; 93% had trauma histories and 32% had PTSD 70-90% incarcerated girls – sexual, physical, emotional abuse 70-90% incarcerated girls – sexual, physical, emotional abuse (DOC, 1998, Chesney & Sheldon, 1991) Canadian study of 187 adolescents reported 42% had PTSD Canadian study of 187 adolescents reported 42% had PTSD 17

Prevalence of Trauma Substance Abuse Population – U.S. Up to two-thirds of men and women in SA treatment report childhood abuse & neglect (SAMSHA CSAT, 2000) Study of male veterans in SA inpatient unit – –77% exposed to severe childhood trauma – –58% history of lifetime PTSD (Triffleman et al., 1995) 50% of women in SA treatment have history of rape or incest (Governor's Commission on Sexual and Domestic Violence, Commonwealth of MA, 2006) 18

Seclusion and Restraint: The Disgraceful Reality

Other Critical Trauma Correlates: The Relationship of Childhood Trauma to Adult Health Adverse Childhood Events (ACEs) have serious health consequences Adverse Childhood Events (ACEs) have serious health consequences Adoption of health risk behaviors as coping mechanisms 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 Severe medical conditions: heart disease, pulmonary disease, liver disease, STDs, GYN cancer Early Death Early Death (Felitti et al., 1998) 20

Adverse Childhood Experiences –Recurrent and severe physical abuse –Recurrent and severe emotional abuse –Sexual abuse Growing up in household with: 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 (Fellitti et al, 1998) 21

ACE Study “Male child with an ACE score of 6 has a 4600% increase in likelihood of later becoming an IV drug user when compared to a male child with an ACE score of 0. Might heroin be used for the relief of profound anguish dating back to childhood experiences? Might it be the best coping device that an individual can find?” (Felitti et al, 1998) “Male child with an ACE score of 6 has a 4600% increase in likelihood of later becoming an IV drug user when compared to a male child with an ACE score of 0. Might heroin be used for the relief of profound anguish dating back to childhood experiences? Might it be the best coping device that an individual can find?” (Felitti et al, 1998) 22

ACE Study Is drug abuse self-destructive or is it a desperate attempt at self-healing, albeit while accepting a significant future risk?” (Felitti, et al, 1998) Is drug abuse self-destructive or is it a desperate attempt at self-healing, albeit while accepting a significant future risk?” (Felitti, et al, 1998) 23

ACE Study “Addiction is best viewed as an understandable, unconscious, compulsive use of psychoactive materials in response to abnormal, prior life experiences, most of which are concealed by shame, secrecy, and social taboo.” (Felitti et al, 1998) “Addiction is best viewed as an understandable, unconscious, compulsive use of psychoactive materials in response to abnormal, prior life experiences, most of which are concealed by shame, secrecy, and social taboo.” (Felitti et al, 1998) 24

Sexual Trauma and Addiction 208 African-American Women with histories of crack cocaine use 208 African-American Women with histories of crack cocaine use Of those Women, those with history of sexual trauma (n=134) reported being addicted to more substances than those who had not been sexually traumatized (n=74) Of those Women, those with history of sexual trauma (n=134) reported being addicted to more substances than those who had not been sexually traumatized (n=74) The Women with trauma histories reported more prior treatment failures than those without. The Women with trauma histories reported more prior treatment failures than those without. (Young & Boyd, 2000) 25

What does the prevalence data tell us? The majority of adults and children in psychiatric treatment settings have trauma histories The majority of adults and children in psychiatric treatment settings have trauma histories A sizable percentage of people with substance use disorders have traumatic stress symptoms that interfere with achieving or maintaining sobriety A sizable percentage of people with substance use disorders have traumatic stress symptoms that interfere with achieving or maintaining sobriety A sizable percentage of adults and children in the prison or juvenile justice system have trauma histories A sizable percentage of adults and children in the prison or juvenile justice system have trauma histories (Hodas, 2004, Cusack et al., Mueser et al., 1998, Lipschitz et al., 1999, NASMHPD, 1998) 26

27 Prevalence of Trauma “Many providers may assume that abuse experiences are additional problems for the person, rather than the central problem…” (Hodas, 2004)

What does the prevalence data tell us? Growing body of research on the relationship between victimization and later offending Growing body of research on the relationship between victimization and later offending Many people with trauma histories have overlapping problems with mental health, addictions, physical health, and are victims or perpetrators of crime Many people with trauma histories have overlapping problems with mental health, addictions, physical health, and are victims or perpetrators of crime Victims of trauma are found across all systems of care Victims of trauma are found across all systems of care (Hodas, 2004, Cusack et al., Muesar et al., 1998, Lipschitz et al., 1999, NASMHPD, 1998) 28

Therefore…… 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) 29

30 Trauma Informed Care Systems

31 Integrate philosophies of care that guide all clinical interventions Integrate philosophies of care that guide all clinical interventions Are based on current literature Are based on current literature Are inclusive of the survivor's perspective Are inclusive of the survivor's perspective Are informed by research and evidence of effective practice Are informed by research and evidence of effective practice Recognize that coercive interventions cause traumatization and re-traumatization and are to be avoided Recognize that coercive interventions cause traumatization and re-traumatization and are to be avoided Trauma Informed Care Systems Key Principles (Fallot & Harris, 2002; Ford, 2003; Najavits, 2003)

32 Trauma Informed Care Systems Key Features Valuing the individual in all aspects of care Valuing the individual in all aspects of care Neutral, objective and supportive language Neutral, objective and supportive language Individually flexible plans and approaches Individually flexible plans and approaches Avoid shaming or humiliation at all times Avoid shaming or humiliation at all times (Fallot & Harris, 2002; Cook et al., 2002; Ford, 2003; Cusack et al. 2003; Jennings, 1998; Prescott, 2000)

33 Trauma Informed Care Systems Key Features Focusing on what happened to you in place of what is wrong with you Focusing on what happened to you in place of what is wrong with you (Bloom, 2002) Asking questions about current abuse Asking questions about current abuse –Addressing the current risk and developing a safety plan for discharge One person sensitively asking the questions One person sensitively asking the questions Noting that people who are psychotic and delusional can respond reliably to trauma assessments if questions are asked appropriately Noting that people who are psychotic and delusional can respond reliably to trauma assessments if questions are asked appropriately (Rosenburg, 2001)

Trauma Informed Non Trauma Informed Trauma Informed Non Trauma Informed Recognition of high prevalence of trauma Recognition of high prevalence of trauma Recognition of primary and co- occurring trauma diagnoses Recognition of primary and co- occurring trauma diagnoses Assess for traumatic histories & symptoms Assess for traumatic histories & symptoms Recognition of culture and practices that are re-traumatizing Recognition of culture and practices that are re-traumatizing Lack of education on trauma prevalence & “universal” precautions Lack of education on trauma prevalence & “universal” precautions Over-diagnosis of Schizophrenia & Bipolar D., Conduct D. & singular addictions Over-diagnosis of Schizophrenia & Bipolar D., Conduct D. & singular addictions Cursory or no trauma assessment Cursory or no trauma assessment “Tradition of Toughness” valued as best care approach “Tradition of Toughness” valued as best care approach 34

Trauma Informed Non Trauma Informed Power/control minimized - constant attention to culture Power/control minimized - constant attention to culture Caregivers/supporters – collaboration Caregivers/supporters – collaboration Address training needs of staff to improve knowledge & sensitivity Address training needs of staff to improve knowledge & sensitivity Keys, security uniforms, staff demeanor, tone of voice Keys, security uniforms, staff demeanor, tone of voice Rule enforcers – compliance Rule enforcers – compliance “Patient-blaming” as fallback position without training “Patient-blaming” as fallback position without training 35

Trauma Informed Non Trauma Informed Staff understand function of behavior (rage, repetition- compulsion, self-injury) Staff understand function of behavior (rage, repetition- compulsion, self-injury) Objective, neutral language Objective, neutral language Transparent systems open to outside parties Transparent systems open to outside parties Behavior seen as intentionally provocative Behavior seen as intentionally provocative Labeling language: manipulative, needy, “attention-seeking” Labeling language: manipulative, needy, “attention-seeking” Closed system – advocates discouraged Closed system – advocates discouraged 36 (Fallot & Harris, 2002; Cook et al., 2002, Ford, 2003, Cusack et al., Jennings, 1998, Prescott, 2000)

37 Organizational Commitment to Trauma Informed Care

38 Organizational Commitment to Trauma Informed Care Adoption of a trauma informed policy to include: Adoption of a trauma informed policy to include: –commitment to appropriately assess trauma –avoidance of re-traumatizing practices Key administrators get on board Key administrators get on board Resources available for system modifications and performance improvement processes Resources available for system modifications and performance improvement processes Education of staff is prioritized Education of staff is prioritized (Fallot & Harris, 2002; Cook et al., 2002)

39 Organizational Commitment to Trauma Informed Care Unit staff can access expert trauma consultation Unit staff can access expert trauma consultation Unit staff can access trauma-specific treatment if indicated Unit staff can access trauma-specific treatment if indicated (Fallot & Harris, 2002; Cook et al., 2002)

40 Organizational Commitment to Trauma Informed Care Assessment data informs treatment planning in daily clinical work Assessment data informs treatment planning in daily clinical work Advance directives, safety plans and de- escalation preferences are communicated and used Advance directives, safety plans and de- escalation preferences are communicated and used Power & Control are minimized by attending constantly to unit culture Power & Control are minimized by attending constantly to unit culture (Fallot & Harris, 2002; Cook et al., 2002)

41 Summary / Take Home Train/Supervise Staff in Prevalence, Impact, Treatment Philosophy, and Interventions Train/Supervise Staff in Prevalence, Impact, Treatment Philosophy, and Interventions Thorough and Sensitive Trauma Assessments Thorough and Sensitive Trauma Assessments Organizational Culture: Physical, Treatment & Support Environments Infused with Recovery Focus (e.g., Respect/Kindness/Collaboration & Empowerment/Hope) Organizational Culture: Physical, Treatment & Support Environments Infused with Recovery Focus (e.g., Respect/Kindness/Collaboration & Empowerment/Hope)

New Zealand and Trauma Informed Care Best Practice in the Reduction and Elimination of Seclusion and Restraint Best Practice in the Reduction and Elimination of Seclusion and Restraint Seclusion: Time for Change O’HaganM, Divis M, Long J. (2008) Action Plan Action Plan developing alternatives to the use of seclusion and restraint in new zealand mental health inpatient settings seclusion: time for change (December 2008) The Journey Forward The Journey Forward Discussion Paper: Trauma and Service Response to Trauma (Dr. Emily Street, Consultant Clinical Psychologist -December 2007)

Joan Gillece, Ph.D. NASMHPD Project Manager National Center for Trauma Informed Care (NCTIC) SAMHSA Funded

9/8/ “I have learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.” -Maya Angelou Novelist, Poet