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Download Trauma Informed Care - West Virginia Child Care Association
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Trauma Informed Care The participant will understand: Sources of potential trauma and complex trauma for individuals served by child serving systems. Impact of trauma on emotional and behavioral functioning Principles of trauma-informed systems. Ways to decrease the possibility that those seeking services and staff experience trauma. “an emotional shock that creates significant and lasting damage to a person’s mental, physical and emotional growth.” Traumatic experiences can significantly alter a person’s perception of themselves, their environment, and the people around them. In effect, trauma changes the way people view themselves, others and their world. Can impact safety, well-being, permanence. This is Anna at age one. This is Anna years later – in a mental institution. What happened? 70‐80% of mental health clients have severe trauma histories In state hospitals, estimates range up to 95% 90% or more of women in jails and prisons are victims of physical or sexual abuse Up to 2/3 of men and women in substance abuse treatment report childhood abuse or neglect Similar statistics exist for foster care, juvenile justice, homeless shelters, welfare programs, etc Boys who experience or witness violence are 1000 times more likely to commit violence Children & women American Indian/Alaska Native Veterans Refugees and immigrants People who are homeless People who are institutionalized in mental health or criminal justice systems Annual Direct Costs: Hospitalization, Mental Health Care System, Child Welfare Service System, Law Enforcement = $33,101,302,133. Annual Indirect Costs: Special Ed, Juvenile Justice, Mental Health & Health Care, Criminal Justice System, Lost Productivity = $70,652,715,359. Total Annual Cost: $103,754,017,492 (over $184 million dollars a day). Economic Impact Study. (September, 2007). Prevent Child Abuse America NOT a diagnostic category A series of experiences that elicits feelings of terror, powerlessness, & out-of-control psychological arousal; result in survival driven behaviors, thoughts, emotions, & needs Often misinterpreted & assigned as symptoms of disorders (depression, Bipolar Disorder, ADHD, Oppositional Defiant Disorder, Conduct Disorder, Attachment Disorder, etc.) Exposure to Trauma Trauma can be: •A single event •A connected series of events •Chronic lasting stress Trauma is under-reported and under-diagnosed. (NTAC, 2004) Loss of a loved one Abandonment Accidents Homelessness Community/school violence Bullying, including cyber-bullying Domestic violence Neglect Frequent moves Serious medical Illness Physical abuse Sexual abuse Emotional/verbal abuse Man-made or natural disasters Witnessing violence Terrorism Refugee and War Zone trauma. Types of Trauma A single traumatic event that is limited in time. The experience of multiple traumatic events. Acute Trauma Chronic Trauma Vicarious Trauma Complex Trauma Both exposure to chronic trauma, and the impact such exposure has on an individual. System Induced Trauma The traumatic removal from home, admission to a detention or residential facility or multiple placements within a short time. Trauma can occur at any age. Trauma can impact anyone. Bridging the gap between childhood trauma and negative consequences later in life. 50% of study participants reported at least one adverse childhood experience 25% reported at least two or more untreated trauma Heart Disease 4 or more traumatic experiences shorten life expectancy by 20 years Chronic Lung Disease Immune Diseases Adverse Childhood Experiences Liver Disease Cancer Diabetes Mental Illness 4 or more traumatic experiences shorten life expectancy by 20 years Relationship Problems Suicide Adverse Childhood Experiences Substance Abuse Behavior Problems Poor SelfEsteem Can cause impairments in many areas of development & functioning, including: Attachment – Difficulty relating to & empathizing with others; believe the world to be uncertain & unpredictable Biology – problems with sensation & movement, including hypersensitivity to physical contact & insensitivity to pain; physical symptoms & increased medical problems Mood Regulation – difficulty identifying & controlling emotions & internal states Behavioral Control - poor impulse control, self-destructive behavior, aggression, risk taking behavior Dissociation – feeling detached, as if observing something happening to them that is not real Cognition – difficult focusing & completing tasks or anticipating future events; learning difficulties & problems with language development Self-concept – feeling shame/guilt; low self-esteem, disturbed body image Loss & Betrayal - loss of part(s) of their life; distrust of others Powerlessness – perceive self as victim; have no say in what happens to them; unable to control their lives, etc. Exposure to Trauma It is an individual’s experience of the event, not necessarily the event itself that is traumatizing. Protective Factors TRIGGERS For trauma survivors, it is different… Triggers Seeing, feeling, hearing, smelling something that reminds us of past trauma Activates the alarm system… The response is as if there is current danger. Thinking brain automatically shuts off in the face of triggers. Past and present danger become confused. We all have buttons that can be pushed… Our experience. A trauma survivor’s experience. Your response is keyNonTrauma Informed Response Trigger Trigger Negative Outcome Trauma Informed Response Positive Outcome Protective Factors • Parental/caregiver resilience • Social connections • Knowledge of parenting and child development • Concrete support in times of need • Nurturing and attachment/social and emotional competence of children Trauma specific treatments are designed specifically to address symptoms of trauma Trauma‐informed services incorporate knowledge about trauma in all aspects of service delivery. TRAUMA INFORMED CARE Providing the foundation for a basic understanding of the psychological, neurological, biological, and social impact that trauma and violence have on many of the individuals we serve. Incorporates proven practices into current operations to deliver services that acknowledge the role that trauma plays in the lives of most of the individuals entering our systems. (NCTIC) Don't look where you fall, but where you slipped. ~African Proverb “It’s about the right to have a present and a future that are not completely dominated and dictated by the past.” Karen Saakvitne TRAUMA INFORMED PRACTICE Trauma Informed Non-Trauma Informed Recognition of high prevalence of trauma Lack of education on trauma prevalence & “universal” precautions Recognition of primary and cooccurring trauma diagnoses Over-diagnosis of Schizophrenia & Bipolar D., Conduct D. & singular addictions Assess for traumatic histories & symptoms Cursory or no trauma assessment Recognition of culture and practices that are re-traumatizing “Tradition of Toughness” valued as best care approach TRAUMA INFORMED PRACTICE Trauma Informed Non-Trauma Informed Power/control minimized - constant attention to culture Keys, security uniforms, staff demeanor, tone of voice Caregivers/supporters – collaboration Rule enforcers – compliance Address training needs of staff to improve knowledge & sensitivity “Patient-blaming” as fallback position without training Staff understand function of behavior (rage, repetitioncompulsion, self-injury) Behavior seen as intentionally provocative TRAUMA INFORMED PRACTICE Trauma Informed Non-Trauma Informed Objective, neutral language Labeling language: manipulative, needy, “attention-seeking” Transparent systems open to outside parties Closed system – advocates discouraged (Fallot & Harris, 2002; Cook et al., 2002, Ford, 2003, Cusack et al., Jennings, 1998, Prescott, 2000) Is alcohol/substance abuse a desperate attempt at selfhealing? (Felitti, et al, 1998) Trauma Informed Systems UNIVERSAL PRECAUTIONS Presume that every person in a treatment setting has been exposed to abuse, violence, neglect, or other traumatic event(s). “What has happened to you?” Though no one can go back and make a brand new start, anyone can start from now and make a brand new ending. Carl Bard Trauma is when people live with more fear than hope. Trauma Recovery is when people live with more hope than fear… How kids cope with trauma determined by: How they experience what they are exposed to Who they were exposed to in their traumatic past What they are exposed to in the present environment Trauma-Informed Care provides a new paradigm under which the basic premise for organizing services is transformed from “What’s wrong with you?” “What happened to you?” 38 S U C C E S S What happened to you? Maximize child’s sense of security Assist youth in reducing overwhelming emotion. Help youth make new meaning of trauma history & current experiences. Address impact of trauma & subsequent changes in youth’s behavior, development & relationships. Coordinate services with other agencies/systems. Utilize comprehensive assessment of trauma experiences & their impact on development & behavior to guide services Support & promote positive & stable relationships in the life of the youth. Provide support & guidance to the youth’s family & caregivers. Manage professional & personal stress. When an agency takes the step to become trauma-informed, every part of its organization, management, & service delivery system is assessed & potentially modified to include a basic understanding of how trauma impacts the life of individuals seeking services. 42 Trauma-informed organizations, programs, & 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 & programs can be more supportive and avoid retraumatization. 43 Provides the foundation for a basic understanding of the psychological, neurological, biological, and social impact that trauma and violence have on many people. Incorporates proven practices into current operations to deliver services that acknowledge the role that violence and victimization play in the lives of most of the individuals entering our systems. 44 The provision of “trauma-informed care” is a seminal concept in emerging efforts to address trauma in the lives of children, youth and adults. In a trauma-informed system, trauma is viewed as “a defining and organizing experience that forms the core of an individual’s identity.” Source: Harris, M. and Fallot, R.D. (Eds), 2001 Characteristics of trauma-informed services Incorporate knowledge about trauma—prevalence, impact, and recovery—in all aspects of service delivery Hospitable and engaging for survivors Minimize re-victimization Facilitate recovery and empowerment Understanding of Trauma Understanding of the Consumer/Survivor Understanding of Services Understanding of the Service Relationship Understanding of Trauma Traumatic events are not rare; experiences of life disruption are pervasive and common. The impact of trauma is seen in multiple, apparently unrelated life domains. Repeated trauma is viewed as a core life event around which subsequent development organizes. Trauma begins a complex pattern of actions and reactions which have a continuing impact over the course of one’s life. Understanding of the Consumer/Survivor An integrated, whole person view of individuals and their problems and resources “Symptoms” are understood not as pathology but primarily as attempts to cope and survive; what seem to be symptoms may more accurately be solutions A contextual, relational view of both problems and solutions Appropriate and collaborative responsibility allocation Understanding of Services Primary goals are empowerment and recovery Survivors are survivors; their strengths need to be recognized Service priorities are prevention driven Service time limits are determined by survivor selfassessment and recovery/healing needs Risk to the consumer is considered along with risk to the system and the provider Understanding of the Service Relationship A collaborative relationship between the consumer and the provider of her or his choice Both the consumer and the provider are assumed to have valid and valuable knowledge bases The consumer is an active planner and participant in services The consumer’s safety must be guaranteed and trust must be developed over time Safety: Ensuring physical and emotional safety Trustworthiness: Maximizing trustworthiness, making tasks clear, and maintaining appropriate boundaries Choice: Prioritizing consumer choice and control Collaboration: Maximizing collaboration and sharing of power with consumers Empowerment: Prioritizing consumer empowerment and skill-building Services designed specifically to address violence, trauma, and related symptoms and reactions. The intent of the activities is to increase skills and strategies that allow survivors to manage their symptoms and reactions with minimal disruption to their daily obligations and to their quality of life, and eventually to reduce or eliminate debilitating symptoms and to prevent further traumatization and violence. “Don't ever take a fence down until you know why it was put up.” -Robert Frost Screening & Assessment Trauma-informed care refers not only to the recognition of the pervasiveness of trauma, but also to a commitment to identify and address it early, whenever possible. Numerous assessment/diagnostic issues complicate the identification & treatment of trauma. Screening Assessment Identification of PTSD or sub-threshold PTSD symptoms is complicated by the fact that these symptoms mimic symptoms of anxiety and depression Many individuals with PTSD also abuse alcohol and drugs If trauma screening isn’t conducted, these individuals are usually treated as people with just depression, or just anxiety, or other diagnoses Individual is exposed to traumatic event in which: They experienced, witnessed, or were confronted with event/events that involved actual or threatened death or serious injury to themselves or others Response to event included intense fear, helplessness, or horror Combat-related PTSD vs. non-combat related Three categories of symptoms: 1. Re-experiencing; 2. Avoidance; 3. Arousal 1. Re-experiencing: Recurrent re-experiencing of trauma, i.e. flashbacks, nightmares, intrusive thoughts or images Intense psychological and/or physiological reactions to external or internal cues that represent some aspect of the traumatic event(s) 2. Avoidance Symptoms Persistent avoidance of stimuli associated with the trauma, i.e. ▪ ▪ ▪ ▪ ▪ ▪ Thoughts, feelings, conversations Activities, people, places Impaired memory of aspects of trauma Reduced interest or participation in usual activities Feeling detached/estranged from others Restricted range of affect (i.e. unable to feel loving/loved) ▪ Sense of shortened lifespan 3. Persistent symptoms of increased arousal Difficulty falling asleep or staying asleep Frequent irritability or angry outbursts Impaired concentration/focus Hypervigilance Exaggerated startle response Step 1: Ask primary screening questions (complete the circle for any positive response) Screening Questions for Mental Health Have you ever been worried about how you are thinking, feeling, or acting? Has anyone ever expressed concerns about how you were thinking, feeling, or acting? Have you ever harmed yourself or thought about harming yourself? Screening Questions for Substance Abuse Have you ever had any problem related to your use of alcohol or other drugs? Has a relative, friend, physician, counselor, or other person been concerned about your drinking or other drug use or suggested that you cut down or stop drinking/using? Have you ever said to another person, “No, I don’t have an alcohol or drug problem,” when you questioned yourself and felt, maybe I do have a problem? Screening Questions for Trauma Have you ever been hit, kicked, choked, or received a more serious punishment from a parent or other adult? Has anyone ever touched you in a sexual way or made you touch them when you did not want to? Have you had an experience that was so frightening, horrible, or upsetting that you have nightmares, upsetting thoughts or memories that come to your mind against your will or have bodily reactions (felt numb or detached from others/surroundings, been constantly on guard/watchful or easily startled, fast heartbeat, stomach churning, sweatiness, dizziness, etc.) when you are reminded of the event? Make your environment, policies, procedures and interactions empowering, collaborative, safe, and respectful? Include trauma survivors as evaluators, informants, and members of your team? Ensure that staff trauma is also a part of your plan? 64 Questions? Florida Dept. of Children & Families Children’s Mental Health, Jane B. Streit, Ph.D., Sr. Psychologist, 2010. National Child Traumatic Stress Network, Child Welfare Trauma Training Toolkit, 2008. http://www.cdc.gov/ace/prevalence.htm Kerker & Dore (2006). Mental health needs and treatment of foster youth: Barriers and opportunities, American Journal of Orthospychiatry, 76(1), 138-147. Pynoos & al., Issues in the developmental neurobiology of traumatic stress. Annals of the New York Academy of Sciences, 821, 176-193. Perry, B. (2003). The cost of caring: Secondary traumatic stress and the impact of working with high-risk children and families. The Child Trauma Academy. Pecora et al., Assessing the effects of foster care: Early results from the Casey National Alumni Study. Casey Family Programs.
