Providing Trauma-Informed Care to the Homeless and MH PopulationsKristina 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 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

• Adult onset• Single incident• Adequate child

development• Not linked to

mental health disorder

Complex Trauma

• Early onset• Multiple incidents• Extended over time• Highly invasive• Interpersonal• Highly stigmatizing• Vulnerable

Complex Trauma Cont'dDysregulation: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.

Trauma

Substance Use

Trauma

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

ACEAbuse

• Psychological (by parents)

• Physical (by parents)

• Sexual (by anyone)

• Physical neglect• Emotional

neglect

• Substance use• Mental illness

Separation or divorce• Domestic violence• Imprisoned household

member

Household with:

Why the ACE is important…

• 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

Traumatic

Experiences

Coping

Skills

Consequence/Bar

rier

Shame

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

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

Outward Expressions• Anger or defiance• Violence towards others• Truancy• Criminal acts• Perfectionism

Inward Expressions• Withdrawal• Substance use• Perfectionism• Violence to self• Spacing out

Explaining not Excusing Behaviors

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?”

“What’s right with

you?”

Even if the story does not come out, work with people as

if there is a story there.

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

SafetyBest 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.

Unacceptable terms when speaking to or about clients:

Crazy Cray-CrayCuckooB***chyNuttyNutsoNut JobFrequent FlyerOff his/her rockerPiece of workBattyBat S**tPsycho

Any others

Questions?Kristina BechtelLa Crosse County – ISRS300 4th St. N La Crosse, WI 54601kbechtel@lacrossecounty.org608-789-8582

Tonier Cain: Trauma Across the Lifespan

https://www.youtube.com/watch?time_continue=3&v=SXCt0qO6LDY