1. Trauma Informed Care & Behavioral Health Liza Guroff, MA, LCMFT COO, Cornerstone Montgomery

2. What is TRAUMA?  Trauma is any event, usually a non-ordinary one, that harms the body, self, or spirit. It covers a broad range of hurtful experiences, including traumas that involve the physical, sexual, mental or emotional realms of our being (van der Kolk & Fisler 1995; Whitfield 1995).  Emotional and psychological trauma is the result of extraordinarily stressful events that shatter your sense of security, making you feel helpless and vulnerable in a dangerous world.  Trauma is an internal experience

3.  It can be a single event  More often than not it is multiple events over time (complex, prolonged trauma)  Trauma and traumatic events include personal and private experiences and public experiences  Example of personal and private events:  Sexual assault  Sexual abuse  Domestic violence/interpersonal violence  Witnessing domestic violence  Examples of public trauma/traumatic events:  Natural disasters  War  Community violence TRAUMA

4.  Perception of trauma varies among individuals  Trauma is something that overwhelms our coping capacity  Affects the whole self  Physical  Emotional  Intellectual  Spiritual Impact of Trauma

5. Normal Response to Traumatic Events  Feelings become intense and sometimes are unpredictable.  Thoughts and behavior patterns are affected by the trauma.  Recurring emotional reactions are common.  Interpersonal relationships often become strained.  Physical symptoms may accompany the extreme stress.

6. Responses to Traumatic Events (in the moment)  Physical  Aches and pains such as headaches, backaches, etc.  Weakness, dizziness, and fatigue most of the time.  Heart palpitations, profuse sweating and chills  Changes in sleep patterns  Changes in appetite and digestive problems  Being easily startled by noises and/or unexpected touch.  Increased susceptibility to allergies, colds, and illnesses.  Increased alcohol consumption and/or substance abuse.  Emotional  Anxiety, Depression, Mood swings, Self-destructive behavior, Flashbacks, Numbness and Phobias

7. Resiliency Resiliency is the capability of individuals to cope successfully in the face of significant change, adversity, or risk. The capacity changes over time and is enhanced by protective factors in the individual and environment. (steward et al., 1991)

8. Protective Factors There are behaviors, characteristics and qualities inherent in some personalities that will assist in recovery after exposure to a traumatic event Environment A reliable support system (friends, family) Access to safe and stable housing Timely and appropriate care from first responders Behaviors Good self care such as: sleeping at least 8 hours a night Eating nutritious foods Exercise Practicing good boundaries Using positive coping mechanisms verses negative coping mechanisms

9. Managing Trauma Impact  Re-Experiencing Symptoms  Avoidance Symptoms

10. Trauma’s effect on the brain is physiological

11. How Trauma Affects the Brain  Can’t find the words to express your thoughts?  Prefrontal lobe (responsible for language) can be adversely affected by trauma, which gets in the way of linguistic function  Can’t regulate your emotions?  Amygdala (responsible for emotional regulation) is in such overdrive that in some PTSD survivors it actually enlarges  Having problem with short-term memory loss?  Hippocampus (responsible for memory and experience assimilation) actually shrinks in volume  Always feeling frightened no matter what you do?  Medial prefrontal cortex (responsible for regulating emotion and fear responses) doesn't regulate itself or function properly after trauma

12. ADVERSE CHILDHOOD EXPERIENCES (ACE) STUDY

13. The ACE Study findings suggest that certain experiences are major risk factors for the leading causes of illness and death as well as poor quality of life in the United States. Progress in preventing and recovering from the nation's worst health and social problems is likely to benefit from understanding that many of these problems arise as a consequence of adverse childhood experiences.

14. ACE Definitions  The following 3 main categories occur in the participant's first 18 years of life.  Abuse;  Emotional Abuse - Physical Abuse - Sexual Abuse  Neglect;  Emotional Neglect - Physical Neglect  Household Dysfunction;  Mother Treated Violently - Household Substance Abuse - Household Mental Illness  Parental Separation or Divorce - Incarcerated Household Member

15. Finding the ACE Score 1. Did a parent or other adult in the household often or very often… – Swear at you, insult you, put you down, or humiliate you? Or Act in a way that made you afraid that you might be physically hurt? 2. Did a parent or other adult in the household often or very often… – Push, grab, slap, or throw something at you? Or Ever hit you so hard that you had marks or were injured? 3. Did an adult or person at least 5 years older than you ever… – Touch or fondle you or have you touch their body in a sexual way? Or Attempt or actually have oral, anal, or vaginal intercourse with you? 4. Did you often or very often feel that … – No one in your family loved you or thought you were important or special? Or Your family didn’t look out for each other, feel close to each other, or support each other? 5. Did you often or very often feel that … – You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? Or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it? 6. Were your parents ever separated or divorced? 7. Was your mother or stepmother: – Often or very often pushed, grabbed, slapped, or had something thrown at her? Or Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? Or Ever repeatedly hit at least a few minutes or threatened with a gun or knife? 8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs? 9. Was a household member depressed or mentally ill, or did a household member attempt suicide? 10. Did a household member go to prison? Now add up your “Yes” answers: _______ This is your ACE Score

16. ACE Original Study Findings  Adverse childhood experiences are surprisingly common, although typically concealed and unrecognized.  ACEs still have a profound effect 50 years later, although now transformed from psychosocial experience into organic disease, social malfunction, and mental illness.  Adverse childhood experiences are the main determinant of the health and social well-being of the nation.

17. Risk Factors For those with up to a maximum of 4+ ACEs, the following risk factors and disease conditions were found to be substantially more common (compared to those persons with 0 ACES): Risk Factor & Compared to those disease conditions persons with no ACES): Severe obesity 1.6 x Diabetes 1.6 x Cigarette Smokers 2 + x Fair/poor health 2.2 x Hepatitis/jaundice 2.4 x Had an STD 2.5 x 50+ intercourse partners 3.2 x COPD 3.9 x Depressed 2 weeks 4.6 x Illegal drug use 4.7 x Alcoholic 7.4 x Injected drugs 10.3 x Suicide attempt 12.2 x

18. ACE on Health & Well-Being

19. Trauma Informed Care  “Trauma-Informed Care is a strengths-based framework that is grounded in an understanding of and responsiveness to the impact of trauma, that emphasizes physical, psychological, and emotional safety for both providers and survivors to rebuild a sense of control and empowerment.” (Hopper et al, 2010)  “Trauma-informed organizations, programs, and services are based on an understanding of the vulnerabilities or triggers of trauma survivors that traditional service delivery approaches may exacerbate, so that these services and programs can be more supportive and avoid re-traumatization.” (SAMHAS)

20.  Aims to avoid re-victimization  Appreciates many problem behaviors began as understandable attempts to cope  Strives to maximize choices for the survivor and control over the healing process  Seeks to be culturally competent  Understands each survivor in the context of life experiences and cultural background Trauma Informed Care Tenets

21. Core Principles of TIC  Awareness: Everyone knows the role of trauma  Safety: Ensuring physical and emotional safety  Trustworthiness: Maximizing trustworthiness, making tasks clear, and maintaining appropriate boundaries  Choice: Respect and prioritize consumer choice and control  Collaboration: Maximizing collaboration and sharing of power with consumers  Empowerment: Prioritizing consumer empowerment and skill-building

22. 7 Domains of Trauma Informed Care (National Council for Behavioral Health) Domain 1: Early Screening and Comprehensive Assessment Domain 2: Consumer Driven Care and Services Domain 3: Trauma-Informed, Educated and Responsive Workforce Domain 4: Trauma-Informed, Evidence Based and Emerging Best Practices Domain 5: Safe and Secure Environments Domain 6: Community Outreach and Partnership Building Domain 7: Ongoing Performance Improvement

23. How to Provide TIC Services  Listen  What is the survivor saying to you?  What is the survivor not saying?  How is the survivor saying it?  Inform  What information do you have that may help her?  What will happen next in the process?  Why is the information important for her to have?  How can your services can help her?

24.  To the best of your ability and within your given time constraints:  Lose the labels  Let person tell their story  Give person time and space to tell their story  Let the survivor lead  Respect their voice and choice  Recognize the survivor’s comfort level  Consider the survivor’s perspective from their cultural context How to Provide TIC Services (continued)

25. TIC Tips  Offer support and validation  Communicate care and concern  Avoid passing judgment  Ask questions of the survivor  Find out if she is experiencing some kind of violence or coercion in her life  Listen to what she has to say  Resist interrupting her  Make sure your body language is receptive  Offer information and assistance  Give her a resource card, a phone number, or a website  Refer her to an advocate (warm hand-off)  Tell her you are available to her in the future

26.  Be yourself  even if you don't know what to say. Acknowledging what they have been through can help.  Ask how they are feeling, as it may not be obvious.  Don't worry if they get upset - this is a natural reaction. Remember that they may not wish to talk about the incident. Ask them if there is anything you can do.  Understand it may be difficult for them to feel motivated or to meet deadlines, and their ability to concentrate may be affected.  With their permission, inform others about the situation. TIC Tips (continued)

27.  Ask about arranging extra help and support for them. It may be helpful for them to take short breaks.  Understand that they may be dealing with a number of issues and emotions.  Help by treating them the same as everyone else.  Understand that their feelings are likely to change over time.  It can be helpful to discuss with them setting new plans and challenging projects. TIC Tips (Continued)

28. D C Rape Crisis Center; (202) 232-0789 http://dcrapecrisiscenter.org/ ______________________________________________________________________ National Sexual Assault Hotline - 1.800.656.HOPE http://www.rainn.org/get-help/national-sexual-assault-hotline or http://centers.rainn.org/http://centers.rainn.org/ ________________________________________________________________________ http://www.mcasa.org/for-survivors/maryland-rape-crisis-and-recovery-centers-5/ ________________________________________________________________________ 24-hour hotline at 1-800-310-7273 or 410-820-5600. http://www.forallseasonsinc.org/MD-rape-crisis-center.htm _______________________________________________________________________ Maryland Rape Recovery Centers http://fha.dhmh.maryland.gov/ohpetup/rapenomore/SitePages/rape-crisis-centers.aspx Support Options

29. Disaster Distress Helpline 1-800-985-5990 or Text TalkWithUs to 66746 http://webcache.googleusercontent.com/search?q=cache:http://www.disasterdistress.samhsa.gov/ ______________________________________________________________________ _____ Call the Safe Helpline at 877-995-5247 https://safehelpline.org/effects-of-sexual-assault/post-traumatic-stress-disorder ____________________________________________________________________ Trauma Survivors Support Group Contact: Katharine Moore: 410-328-1375 or kmoore3@umm.edu Source:http://www.umm.edu/shocktrauma/trauma_survivors_network/programs.htm #ixzz2KpT9vCSUhttp://www.umm.edu/shocktrauma/trauma_survivors_network/programs.htm #ixzz2KpT9vCSU ___________________________________________________________ 24 hour hotline: (210)349-7273 http://www.rapecrisis.com/

30. References  The Relationship of Adverse Childhood Experiences to Adult Health: Turning gold into lead by Vincent J. Felitti1  For more information about the ACEs study click here (http://nccanch.acf.hhs.gov/profess/conferences/cbconference/fourteenth/presentations/ahdc/index.cfm) or visit http://www.sanctuaryweb.com/main/ACEs%20Study.htmhttp://nccanch.acf.hhs.gov/profess/conferences/cbconference/fourteenth/presentations/ahdc/index.cfm http://www.sanctuaryweb.com/main/ACEs%20Study.htm  Adverse Childhood Experiences and Trauma Editorial, Charles L. Whitfield  Helpguid.org http://www.helpguide.org/mental/emotional_psychological_trauma.htmhttp://www.helpguide.org/mental/emotional_psychological_trauma.htm  The Health and Social Impact of Growing Up With Adverse Childhood Experiences, Robert Anda, MD, MS  http://www.apa.org/helpcenter/recovering-disasters.aspx http://www.apa.org/helpcenter/recovering-disasters.aspx  Intensive Trauma Therapy- A Different Approach to the Treatment of Trauma and Dissociative Disorders – http://www.traumatherapy.us/treatmenteffects.htm  http://www.theravive.com/services/trauma-counselling.htm http://www.theravive.com/services/trauma-counselling.htm  http://www.thesurvivorsclub.org/health/neurological/trauma-and-the-brain-understan Trauma and the Brain: Understanding What Happens and Why You Feel Changed http://www.thesurvivorsclub.org/health/neurological/trauma-and-the-brain-understan  http://www.headington-institute.org/Default.aspx?tabid=2073 How can trauma affect your body and mind http://www.headington-institute.org/Default.aspx?tabid=2073  http://www.businesslink.gov.uk/bdotg/action/detail?itemId=1085296180&type=RESOURCES How to deal with stress: Working with people affected by traumatic events http://www.businesslink.gov.uk/bdotg/action/detail?itemId=1085296180&type=RESOURCES  http://www.aaets.org/article164.htm Dealing With Crisis and Traumatic Events; Binghamton University Counseling Center http://www.aaets.org/article164.htm  http://www.medicalwellnessassociation.com/articles/traumatic_events.htm Medical Wellness Archives; Living Through and Surviving Traumatic Events; 2005: Volume 2, Number 2 http://www.medicalwellnessassociation.com/articles/traumatic_events.htm  Trauma-Focused Cognitive-Behavioral Therapy for Sexually Abused Children; By Judith A. Cohen, M.D., Esther Deblinger, Ph.D., and Anthony Mannarino, Ph.D. | September 1, 2004  Trauma Informed Care Stakeholders Group Training Subcommitteehttp://www.traumainformedcareproject.org/resources/Trauma%20101%20Powerpoint%20PresentationV1.pdf  Trauma Informed Car and Effective Screening www.dhs.state.or.us/caf/dv/trauma-informed-care.pptxwww.dhs.state.or.us/caf/dv/trauma-informed-care.pptx  http://nation.time.com/2011/06/05/the-disappearing-disorder-why-ptsd-is-becoming-pts/ http://nation.time.com/2011/06/05/the-disappearing-disorder-why-ptsd-is-becoming-pts/  http://www.thenationalcouncil.org/topics/trauma-informed-care/ http://www.thenationalcouncil.org/topics/trauma-informed-care/