Kiersten Parker, Youth AdvocateTal Curry, DPH Program Administrator

Trauma Informed Care Overview

FRYSC Fall Institute 2012

When all she wants is…When all she wants is…

DiscussionDiscussion

In the absence of formal recognition or diagnosis for complex traumatic stress disorders, there is the potential mis- or overdiagnosis of severe disorders (e.g., bipolar, schizophrenia spectrum disorders, borderline personality disorder, conduct disorder).

(Christine Curtois and Julian Ford, “Treating Complex Traumatic Stress Disorders,” 2009)

In the absence of formal recognition or diagnosis for complex traumatic stress disorders, there is the potential mis- or overdiagnosis of severe disorders (e.g., bipolar, schizophrenia spectrum disorders, borderline personality disorder, conduct disorder).

(Christine Curtois and Julian Ford, “Treating Complex Traumatic Stress Disorders,” 2009)

Raise awareness about the often unrecognized prevalence of trauma history

Stimulate thinking around how to take trauma exposure history into account so that…� We don’t re-traumatize� We establish response styles and physical

surroundings that promote healing� We support a strength based perspective

To initiate a dialog which could transform service delivery toward a more trauma sensitive model of care

Raise awareness about the often unrecognized prevalence of trauma history

Stimulate thinking around how to take trauma exposure history into account so that…� We don’t re-traumatize� We establish response styles and physical

surroundings that promote healing� We support a strength based perspective

To initiate a dialog which could transform service delivery toward a more trauma sensitive model of care

Training Objectives

OverviewOverview

Definitions

Prevalence

Understanding Trauma: Its Consequences and Impact

Trauma Informed System of Care

Definitions

Prevalence

Understanding Trauma: Its Consequences and Impact

Trauma Informed System of Care

Imagine...Imagine...

A place where people ask ……. “what happened to you” instead of “what’s wrong with you?"

A place that understands that trauma can be re-triggered.

A place committed to supporting the healing process while ensuring no more harm is done.

A place where people ask ……. “what happened to you” instead of “what’s wrong with you?"

A place that understands that trauma can be re-triggered.

A place committed to supporting the healing process while ensuring no more harm is done.

Trauma is a Public Health ConcernTrauma is a Public Health Concern

“It has become more clear than ever psychological trauma is a primary — but often ignored or overlooked — factor of health (both physical and mental)... this presents a public health crisis in the United States that needs to be addressed immediately.”

From a letter (9-29-06) to President Bush the House Bipartisan Caucus on Addiction, Treatment, and Recovery

“It has become more clear than ever psychological trauma is a primary — but often ignored or overlooked — factor of health (both physical and mental)... this presents a public health crisis in the United States that needs to be addressed immediately.”

From a letter (9-29-06) to President Bush the House Bipartisan Caucus on Addiction, Treatment, and Recovery

What is Trauma Informed Care?

What is Trauma Informed Care?

Service delivery that is directed by

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)

Service delivery that is directed by

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)

What is System of Care?What is System of Care?

1. A philosophy or framework about the way services should be delivered to children and families

2. A community-specific design built:• within this philosophy/framework

• around local/state leadership, political context and funding

• to fit with other initiatives and partnerships

3. Not a model, program or single definable thing

1. A philosophy or framework about the way services should be delivered to children and families

2. A community-specific design built:• within this philosophy/framework

• around local/state leadership, political context and funding

• to fit with other initiatives and partnerships

3. Not a model, program or single definable thing

A Paradigm ShiftA Paradigm Shift

Not simply about trauma aware; but trauma informed

Shifts how we see our clients� What happened to you� Rather than what’s wrong

with you

Shifts how we see their symptoms� Instead of focusing on what w are not good

at, we focus on what we are good at

Shifts how we go about providing services—System of Care

Not simply about trauma aware; but trauma informed

Shifts how we see our clients� What happened to you� Rather than what’s wrong

with you

Shifts how we see their symptoms� Instead of focusing on what w are not good

at, we focus on what we are good at

Shifts how we go about providing services—System of Care

What is trauma?

DSM IV-TR ----PTSD

Defines “traumatic event” as one in which “a person experienced, witnessed or was confronted with an event(s) that involved actual or threatened death or serious injury or threat to the physical integrity of self or others”.

The person’s response involved intense fear, helplessness or horror

DSM IV-TR ----PTSD

Defines “traumatic event” as one in which “a person experienced, witnessed or was confronted with an event(s) that involved actual or threatened death or serious injury or threat to the physical integrity of self or others”.

The person’s response involved intense fear, helplessness or horror

What is Trauma?

Can you identify this picture?

Can you identify this picture?

How does this impact you?

How does this impact you?

What is trauma?What is trauma?“Traumatization occurs when both internal and external resources are inadequate to cope with the external threat” (Van der Kolk, 1989)

Trauma overwhelms the ordinary systems that give people a sense of control, connection and meaning.

Therefore...

“Traumatization occurs when both internal and external resources are inadequate to cope with the external threat” (Van der Kolk, 1989)

Trauma overwhelms the ordinary systems that give people a sense of control, connection and meaning.

Therefore...

Types of trauma resulting in serious persistent mental health

problems:

Types of trauma resulting in serious persistent mental health

problems:Complex trauma- “a psychiatric condition that officially does not exist, but which possibly constitutes the most common set of psychological problems to drive human beings into psychiatric care” (van der Kolk, 2009)Are usually not a “single blow” event e.g. rape, natural disasterAre interpersonal in nature: intentional, prolonged, repeated, severeOccur in childhood and adolescence and may extend over an individual’s life span

Re-victimization

(Terri, 1991; Giller, 1999)

Complex trauma- “a psychiatric condition that officially does not exist, but which possibly constitutes the most common set of psychological problems to drive human beings into psychiatric care” (van der Kolk, 2009)Are usually not a “single blow” event e.g. rape, natural disasterAre interpersonal in nature: intentional, prolonged, repeated, severeOccur in childhood and adolescence and may extend over an individual’s life span

Re-victimization

(Terri, 1991; Giller, 1999)

What prevalence data tells us?

What prevalence data tells us?

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 adults and children in

the prison or juvenile justice system have trauma histories

Victims of trauma are found across all systems of care

Trauma hx often goes undetected (Hodas, 2004, Cusack et al., 2005, Mueser et al., 1998, Lipschitz et al., 1999, NASMHPD, 1998)

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 adults and children in

the prison or juvenile justice system have trauma histories

Victims of trauma are found across all systems of care

Trauma hx often goes undetected (Hodas, 2004, Cusack et al., 2005, Mueser et al., 1998, Lipschitz et al., 1999, NASMHPD, 1998)

Juvenile and Criminal Justice

Juvenile and Criminal Justice

Kentucky, around 30,000 youth are charged with status or public offenses each year (KIDS COUNT Data Book)

Childhood abuse correlated with increased truancy, running away and homelessness (NASMHPD/NTAC, p. 55)

Childhood abuse or neglect increases the likelihood of arrest as a juvenile by 53% and as a young adult by 38%. The likelihood of arrest for a violent crime also increases by 38% (p.49)

PTSD in the juvenile justice population is 8 x’s as high as community samples of similar age peers (Wolpaw & Ford, 2004).

Kentucky, around 30,000 youth are charged with status or public offenses each year (KIDS COUNT Data Book)

Childhood abuse correlated with increased truancy, running away and homelessness (NASMHPD/NTAC, p. 55)

Childhood abuse or neglect increases the likelihood of arrest as a juvenile by 53% and as a young adult by 38%. The likelihood of arrest for a violent crime also increases by 38% (p.49)

PTSD in the juvenile justice population is 8 x’s as high as community samples of similar age peers (Wolpaw & Ford, 2004).

Trauma and Criminal JusticeTrauma and Criminal Justice

US leads the world in the rate of incarceration of its citizens

KY has the fastest growing prison population in the country

Yet, FBI crime reports indicate KY ranks 40th in violent crime

US leads the world in the rate of incarceration of its citizens

KY has the fastest growing prison population in the country

Yet, FBI crime reports indicate KY ranks 40th in violent crime

Prevalence Yields Pervasive

Consequences

Prevalence Yields Pervasive

Consequences

JeremyJeremyQuickTime™ and aH.264 decompressor

are needed to see this picture.

Jeremy Wade DelleJeremy Wade Delle

On January 8, 1991 in Richardson, Tx 16-year old Jeremy Wade Delle--a troubled, beaten, battered and bullied young man entered his english class and spokeHe pulled the trigger of a .357magnum and ended his life in front of his peersJeremy’s pain had spokenEarly childhood trauma is never without impact!

On January 8, 1991 in Richardson, Tx 16-year old Jeremy Wade Delle--a troubled, beaten, battered and bullied young man entered his english class and spokeHe pulled the trigger of a .357magnum and ended his life in front of his peersJeremy’s pain had spokenEarly childhood trauma is never without impact!

Consequences of TraumaConsequences of Trauma

Effects are neurological, biological, psychological and social in nature, including:

Changes in brain neurobiology

Social, emotional and cognitive impairment

Adoption of health risks behaviors as coping mechanisms (eating disorders, smoking, substance abuse, self-harm, sexual promiscuity, violence)--

Severe and persistent behavioral health, social problems, physical health and early death

•

Effects are neurological, biological, psychological and social in nature, including:

Changes in brain neurobiology

Social, emotional and cognitive impairment

Adoption of health risks behaviors as coping mechanisms (eating disorders, smoking, substance abuse, self-harm, sexual promiscuity, violence)--

Severe and persistent behavioral health, social problems, physical health and early death

•

Trauma occurs in layers, with each layer affecting every other layer. Current

trauma is one layer. Former traumas in one’s life are more fundamental layers. Underlying one’s own individual trauma history is one’s group identity or identities and the historical trauma with which they are associated. (Bonnie

Burstow)

Trauma occurs in layers, with each layer affecting every other layer. Current

trauma is one layer. Former traumas in one’s life are more fundamental layers. Underlying one’s own individual trauma history is one’s group identity or identities and the historical trauma with which they are associated. (Bonnie

Burstow)

Therefore...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, 2004)

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, 2004)

The Impact of Trauma

The Impact of Trauma

Importance of AttachmentImportance of Attachment

Traumatic Experience

Floods us w/ physical fear/helplessness

Colors the world as dangerous/unpredictable

Creates overwhelming emotional chaos

Threatens cohesive sense of self

Assaults self-efficacy and sense of control

Scrambles ability to engage fully in present/adapt to new situations

Traumatic Experience

Floods us w/ physical fear/helplessness

Colors the world as dangerous/unpredictable

Creates overwhelming emotional chaos

Threatens cohesive sense of self

Assaults self-efficacy and sense of control

Scrambles ability to engage fully in present/adapt to new situations

Secure Attachment

Soothes and comforts

Offers safe haven

Promotes affect regulation

Promotes personality integration

Promotes confidence/trust in self and others

Promotes openness to experience, and new learning

Secure Attachment

Soothes and comforts

Offers safe haven

Promotes affect regulation

Promotes personality integration

Promotes confidence/trust in self and others

Promotes openness to experience, and new learning

Emotionally Focused Couple Therapy with Trauma Survivors, Susan Johnson, (2002)

What’s the point?What’s the point?

When we are uninformed about trauma, we can accidently re-traumatize

Whether or not a given event evokes a trauma response, particularly with children, greatly depends on the response of caregivers

Each service provider a child/adolescent comes into contact with after a trauma event can either hinder, harm or help stimulate healing

When we are uninformed about trauma, we can accidently re-traumatize

Whether or not a given event evokes a trauma response, particularly with children, greatly depends on the response of caregivers

Each service provider a child/adolescent comes into contact with after a trauma event can either hinder, harm or help stimulate healing

Trauma exposure can re-organize a person around the traumatic event

Trauma exposure becomes both the defining and organizing experience that forms the core of a person’s identity

A whole new meaning system develops which informs and guides attempted coping strategies

Trauma changes the whole person not just in particulars

Trauma exposure can re-organize a person around the traumatic event

Trauma exposure becomes both the defining and organizing experience that forms the core of a person’s identity

A whole new meaning system develops which informs and guides attempted coping strategies

Trauma changes the whole person not just in particulars

Comprehensive Impact

Trauma changes your world view

Exposure to trauma is the rule rather than exception

Consider that many individuals bring a lifetime history of trauma (acute and chronic) which impacts the current precipitant situation

This history often results in alteration of brain structure and function

Exposure to trauma is the rule rather than exception

Consider that many individuals bring a lifetime history of trauma (acute and chronic) which impacts the current precipitant situation

This history often results in alteration of brain structure and function

Summary

Trauma Informed System of Care

Trauma Informed System of Care

Trauma Informed Care:Key Principles

Trauma Informed Care:Key Principles

Integrate philosophies of care that guide all clinical interventions

Are based on current literature

Are inclusive of the survivor’s perspective

Are informed by research and evidence of effective practice

Recognize that coercive interventions cause traumatization and re-traumatization and are to be avoided

(Fallot & Harris, 2002; Ford, 2003; Najavitas, 2003)

Integrate philosophies of care that guide all clinical interventions

Are based on current literature

Are inclusive of the survivor’s perspective

Are informed by research and evidence of effective practice

Recognize that coercive interventions cause traumatization and re-traumatization and are to be avoided

(Fallot & Harris, 2002; Ford, 2003; Najavitas, 2003)

Trauma Informed Care:Key Features

Trauma Informed Care:Key Features

Recognition of the high rates of PTSD and other psychiatric disorders related to trauma exposure in children and adults with SMI/SED

Early and thoughtful diagnostic evaluation with the focused consideration of trauma in people with complicated, treatment-resistant illness

(Fallot & Harris, 2002; Cook et al., 2002; Ford, 2003; Cusack et al.)

Recognition of the high rates of PTSD and other psychiatric disorders related to trauma exposure in children and adults with SMI/SED

Early and thoughtful diagnostic evaluation with the focused consideration of trauma in people with complicated, treatment-resistant illness

(Fallot & Harris, 2002; Cook et al., 2002; Ford, 2003; Cusack et al.)

Trauma Informed Care:Key Features

Trauma Informed Care:Key Features

Valuing the consumer in all aspects of care

Neutral, objective and supportive language

Individually flexible plans and approach

Avoid shaming or humiliation at all times

(Fallot & Harris, 2002; Cook et al., 2002; Ford, 2003; Cusack et al.; Jennings, 1998; Prescott, 2000)

Valuing the consumer in all aspects of care

Neutral, objective and supportive language

Individually flexible plans and approach

Avoid shaming or humiliation at all times

(Fallot & Harris, 2002; Cook et al., 2002; Ford, 2003; Cusack et al.; Jennings, 1998; Prescott, 2000)

Trauma Informed Care:Key Features

Trauma Informed Care:Key Features

Awareness/training on re-traumatizing practices

Institutions that are open to outside parties: advocacy and clinical consultants

Training and supervision in assessment and treatment of people with trauma histories

(Fallot & Harris, 2002; Cook et al., 2002; Ford, 2003; Cusack et al.; Jennings, 1998; Prescott, 2000)

Awareness/training on re-traumatizing practices

Institutions that are open to outside parties: advocacy and clinical consultants

Training and supervision in assessment and treatment of people with trauma histories

(Fallot & Harris, 2002; Cook et al., 2002; Ford, 2003; Cusack et al.; Jennings, 1998; Prescott, 2000)

Universal Precautions: A Core Concept

Universal Precautions: A Core Concept

Presume that every person in a treatment setting has been exposed to abuse,

violence, neglect or other traumatic experiences.

Presume that every person in a treatment setting has been exposed to abuse,

violence, neglect or other traumatic experiences.

Guiding Values of Trauma-Informed Care

“Healing Happens in Relationship”

Guiding Values of Trauma-Informed Care

“Healing Happens in Relationship”

Additional ResourcesAdditional Resources

www.nctsn.orgwww.nctsn.org

www.samhsa.gov/nctic/www.samhsa.gov/nctic/

www.nccp.org

What are three things you will take with you?What are three things you will take with you?

Contact InformationContact Information

Kiersten Parker,

Youth Advocate

&

Tal Curry, LCSW

Tal.Curry@ky.gov

Kiersten Parker,

Youth Advocate

&

Tal Curry, LCSW

Tal.Curry@ky.gov