Recovery ConferenceJune 1 and 2, 2016

Joey Supina, Executive DirectorSandusky Artisans Community Center

Kim Kehl, OMHASTrauma-Informed Care Project Coordinator

Creating safety

• Have a plan for self-care if you should need to take a break

• You are free to choose to not participate in any activity

• We want to hear from you, participate throughout the program

• Silence cell phones • Be respectful of other participants • Have fun…

Slide 2

Learning objectives

1) This program will provide an introduction to trauma and trauma-informed approaches in behavioral health and human services.

2) Participants will have a shared understanding of trauma.

3) Participants will be able to identify examples of a traumatic event.

4) Learn about how prevalent trauma histories are among the people you serve or interact with.

Slide 3

TIC – Why is it Important“What Happened to You?”

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Adverse Childhood Experience Study

Collaboration between Kaiser Permanente and CDC

17,000 patients undergoing physical exam provided detailed information about childhood experiences of abuse, neglect and family dysfunction (1995-1997)

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ACE Categories

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Personal Family

/ Separation

What is Trauma ? The Three E’s

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Potential Traumatic Events

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.

Abuse• Emotional• Sexual• Physical• Domestic violence• Witnessing violence• Bullying• Cyberbulling• Institutional

Loss• Death• Abandonment• Neglect• Separation• Natural disaster• Accidents• Terrorism• War

Chronic Stressors• Poverty• Racism• Invasive medical

procedure• Community trauma• Historical trauma• Family member with

substance use disorder

ACE Score and Health RiskAs the ACE score increases, risk for these health problems increases in a strong and graded fashion:

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The Science on ACEs . . .

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New lens through which to understand the human story

• Why we suffer• How we parent, raise and mentor our children• How we might better prevent, treat and

manage illness in our medical care systems• How we can recover and heal on deeper levels

ACE Score and Health Risk

As the ACE score increases, risk for these health problems increases in a strong and graded fashion:

• Alcoholism and alcohol abuse• Chronic obstructive pulmonary

disease (COPD)• Depression• Hallucinations• Fetal death• Health-related quality of life• Illicit drug use• Ischemic heart disease (IHD)• Liver disease

• Risk for intimate partner violence• Multiple sexual partners• Sexually transmitted diseases

(STDs)• Smoking• Suicide attempts• Unintended pregnancies• Early initiation of smoking• Early initiation of sexual activity• Adolescent pregnancy• HIV

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TraumaticEvent

Hopelessness

Insomnia

Intrusive MemoriesNightmares

Shame & Self Hatred

Somatic Symptoms

Dissociation

Self Destructive Behavior

Eating Disorders

Substance Abuse

Generalized AnxietyPanic Attacks

Depression

Numbing

Hypervigilence

Agitation

Fisher, 2005

Adaptive Responses When Overwhelmed

Slide 12

Additional Signs of Trauma

Flashbacks or frequent nightmares

Sensitivity to noise or to being touched

Always expecting something bad to happen

Not remembering periods of your life

Feeling emotionally numb

Lack of concentration; irritability

Excessive watchfulness, anxiety, anger, shame or sadness

Slide 13

Problems or Adaptations?

• Fight – Non-compliant or combative OR struggling to hold on to some personal control/power?

• Flight – Treatment resistant, uncooperative OR disengaging, withdrawing or titrating external stimulus/demands

• Freeze – Passive, unmotivated OR giving in to those in power, repeating cycle of surrender in order not to get hurt

Slide 14

Discussion Question

Let’s discuss why some events may be traumatic for one person but not

for another.

Slide 15

Prevalence of Trauma

Exposure to trauma is widespread• Trauma can occur at any age• Trauma can affect individuals

from all walks of life

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Exposure to trauma is widespread

• 59% of mean and women experience at least one ACE in their life and 9% experience 5 or more

• 48% of children have experienced at least one of nine types of adverse experience

• Children with histories of traumatic experiences are twice as likely to have chronic health conditions

• Children with traumatic experiences are 2 ½ times more likely to have repeated a grade in school

The National Council for Behavioral Health Trauma Matters Infogram - 2015

Indicators highly associated with the incidence of toxic stress, trauma, and the resulting conditions

• Ohio population 11.5 million • 7th most populous state in the US• Approximately 20% of households have children

under the age of 18• 6.2% are under the age of five• Nearly one in four children in Ohio live in households

with incomes less than the Federal poverty level• Close to half live in poverty or near poverty• Poverty is the single best predictor of child abuse and

neglect

18Ohio Department of Health Early Childhood Comprehensive System Grant 2015

• About 20 percent of young children suffer from emotional and behavioral challenges that impair their ability to learn

• The incidence among economically disadvantaged young children is two or three times as high as their more affluent peers

• About 50% receive mental health treatment

• 70% of youth in state and local juvenile justice systems live with a mental health condition

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• More than one third of children live in single-parent families

• The proportion of infants born to single mothers is highest among Blacks at 78%, compared with 58% among Hispanics and 33% among Whites demonstrating a racial disparity

Indicators highly associated with the incidence of toxic stress, trauma, and the resulting conditions

Social emotionalChildren in Single Parent Households

Ohio Department of Health Early Childhood Comprehensive System Grant 2015

• In 2013 there were 100,139 new reports of child abuse and neglect

• Of these children, 31% were dependent, 25% were neglected, 10% were physically abused, and 5% were sexually abused

• On 1/1 /14 12,679 were in the custody • 6 in 10 children in Ohio’s children welfare system did not

come into the system for reasons primarily related to abuse or neglect, but because of developmental disabilities, mental illness or juvenile justice diversion

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Indicators highly associated with the incidence of toxic stress, trauma, and the resulting conditions

Child Abuse and Neglect

PCSAO Budget fact Sheet - 2015

• Ohio’s infant mortality rate is among the worst in the nation.

• Black babies are more likely to die within the first year of life even when controlling for social and economic factors

• Metropolitan and Appalachian counties have higher rates of infant mortality

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• Evidence suggests that children in foster care have higher-than-average delinquency rates, teen birth rates, and lower earnings

• Abuse and neglect is a leading factor in infant and child fatalities

Indicators highly associated with the incidence of toxic stress, trauma, and the resulting conditions

Maternal and Child Health Indicators

Ohio Department of Health Early Childhood Comprehensive System Grant 2015

Trauma in person with developmental disabilities

• One out of every three children and adults with developmental disabilities will experience abuse in their lifetime (Envision 2014)

• More that 90% of the time, that abuse will be inflicted by the very person they rely on to protect and support them (Envision 2014)

• With limited verbal skills, they may not have been able to tell anyone. And just because the actual traumatic event is over, it continues to play out in one's response to future situations (Envision 2014)

• Choose to judge behavior less and seek to understand what might be underneath and behind it; we must always be particularly cautious of seeing behavior as attention-seeking or manipulative (Envision 2014)

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Trauma in person with developmental disabilities

Abuse and neglect have profound influences on braindevelopment. The more prolonged the abuse orneglect, the more likely it is that permanent braindamage will occur.

Not only are people with developmental disabilitiesmore likely to be exposed to trauma, but exposure totrauma makes developmental delays more likely.

Joan Gillece, Ph.D. ,NASMHPD

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Trauma Affects…

Origins of Addiction: Vincent Felitti, 2004

• A male child with an ACE Score of 6, when compared to a male child with an ACE Score of 0, has a 46-fold (4,600%) increase in the likelihood of becoming an injection drug user sometime later in life

• ACEs. Population Attributable Risk* (PAR) analysis shows that 78% of drug injection by women can be attributed to adverse childhood experiences

• For men and women combined, the PAR is 67%

• Might drugs 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, 1998)

Percentage of Children Who Have Experienced at Least Two Traumas, Compared to the National Average

Prevalence of kids who experienced at least two traumas, compared to the U.S. average (Health Affairs)

Trauma Affects Transition-age Youth . . .

• More than 44,000 women under the age of 25 gave birth in 2013; of those, one more than one in 10 delivered low birth weight babies

• Close birth spacing which is a significant poverty risk factor, continues to be most prevalent for transition-age youth

• At the most recent 2013 Point-In-Time HUD report to congress, transitional age youth made up 10 percent of the nation’s homeless population

US Department of Housing and Urban Development, October 2014American Institutes for Research and National Center on Family Homelessness 2010 , SHIFT Study

Trauma Affects Ohioans withDomestic Violence . . .

Of families who experience intimate partner violence:

• Four out of five adult children commitviolence against partners

• Three out of four adult children become victims of domestic violence

Children exposed to domestic violence may develop a widerange of problems, including interpersonal skill deficits,psychological and emotional problems such as depression and PTSD, and externalizing behavior problems.

Barbara Warner Committee on Workplace Domestic Violence -2013 Report, Ohio Department of Health Ohio Domestic Violence Statistics, 2012, Ohio Domestic Violence Network HealthDay, Copyright © 2013 Carlson, B. E. (2000). Children exposed to intimate partner violence: Research findings and implications for ntervention. Trauma, Violence and Abuse, 1(4), 321-342.

Trauma Affects Ohioans Who Are Victims of Human Trafficking . . .

1,000 Ohio children are estimated to become victims of human trafficking each year

An additional 3,000 more children are at risk of becoming victims

http://humantrafficking.ohio.gov

ACE score and current smoking

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ACE Score

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0 1 2 3 4 > 5

A child with 6 or more categories of adverse childhood experiences is 250% more likely to become an adult smoker .Smoking may not be caused by existence of local gas station availability or genetic predisposition

Childhood experiences andadult alcoholism

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• A 500% increase in adult alcoholism is directly related to adverse childhood experiences.

• 2/3rds of all alcoholism can be attributed to adverse childhood experiences

• This certainly suggests that alcoholism, contrary to popular belief, may not be simply a disease – but rather be a means by which the individual has learned to ease the pain of the trauma – or to balance his/her nervous system – e.g. sooth anxiety.

• Important ALWAYS to address and treat trauma along with alcoholism. 0

2

4

6

8

10

12

14

16

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ACE Score

0

1

2 3

4 or more

Alco

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Childhood experiences underlie suicide risk

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5

10

15

20

25

% A

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ACE Score

4 or more

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The likelihood of adult suicide attempts increased 30-fold, or 3,000%,with an ACE score of 7 or more.

• Attributable to ACEs– People with an

ACE score of 4 or more are over 8 times more likely to be a victim of rape than people with an ACE score of 0.

Adverse childhood experiences underlie being a victim of rape

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"We have this incredible proof about the expense that trauma is causing our

society and how all of these physical ailments are related. And yet, what do

you do to change it? It’s not like, ‘Well, eat more broccoli.’ “

Patricia Wilcox, head of the Traumatic Stress Institute at Klingberg Family Centers in New Britain

ACE Study . . .

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The ACE study indicates:Adverse childhood experiences are the

most basic and long-lasting cause of health risk behaviors, mental illness,

social malfunction, disease, disability, death, and healthcare costs

Cost of Trauma

Trauma is a major driver of medical illness, including cardiac disease and cancer

Addressing trauma can positively impact the physical, behavioral, social and economic health of Ohio and Ohioans

A study by Felittli, et.al. found patients who were asked trauma-oriented questions had 35 percent fewer doctor office visits and 11 percent fewer emergency room visits

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How does ACES affect our society?

What is “Trauma Informed”?

A program, organization or system that is trauma-informed:• Realizes the widespread prevalence and impact of trauma • Understands potential paths for healing• Recognizes the signs and symptoms of trauma and how

trauma affects all people in the organization, including:• Consumers/patients• Staff• Families• Others involved with the system

• Responds by fully integrating knowledge about trauma into practices, policies, procedures, and environment.

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Key Principles of Trauma-Informed Care

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• Safety• Trustworthiness and transparency• Collaboration and mutuality• Empowerment• Voice and choice• Peer support and mutual self-help• Cultural, historical and gender issues

Outcomes with TIC

• Improved quality of care and impact of care• Improved safety for patients and staff• Decreased utilization of seclusion and restraint• Fewer no-shows• Improved patient engagement• Improved patient satisfaction• Improved staff satisfaction• Decreased “burnout” and staff turnover

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Ohio’s Trauma-Informed Care (TIC) Initiative

Vision:To advance Trauma-Informed Care in Ohio

Mission:To expand opportunities for Ohioans to receive trauma-informed interventions by enhancing efforts for practitioners, facilities, and agencies to become competent in trauma- informed practices

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Trauma-Informed Care (TIC) Promotes Cultural Change

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“How do I understand this person?”

rather than“How do I understand this problem

or symptom?”

Framework for Ohio’s TIC Initiative

Regional Collaboratives• Progressively transmit TIC and increase expertise

within regions• Facilitate cultural change within organizations,

addressing gaps and barriers and taking effective steps based on the science of implementation

• Topical workgroups (prevention, DD, child, older adult, etc.)

• Department(s) continue to support, facilitate,communicate

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Athens Region

Lawrence

Meigs

Gallia

Washington

Monroe

SciotoAdams

Brown

Hamilton

Butler WarrenClinton

Highland

Jackson

RossVinton Athens

PrebleGreene

Fayette

MadisonClark

Miami

Darke Champaign

Franklin

PickawayFairfield

Hocking

Mercer Auglaize

ShelbyLogan

Union

HardinAllen

Van Wert

PauldingPutnam

Hancock

Wyandot

Marion

Delaware

Morrow

Seneca

Sandusky

Ottawa

LucasFultonWilliams

Henry WoodDefiance Erie

Huron

Lorain

Wayne

Medina

Cuyahoga

Summit

Knox

Holmes

Licking

Coshocton

Muskingum

Tuscarawas

Guernsey

PerryMorgan

Noble

Belmont

Harrison

Carroll

ColumbianaStark

Portage

Mahoning

Trumbull

Ashtabula

Geauga

Lake

Crawford

Twin Valley

Region

Lawrence

GalliaScioto

Adams

Hamilton

Pike

Jackson

Vinton Athens

Madison

MiamiDarke

Fairfield

Hocking

Mercer Auglaize

Shelby Union

HardinAllen

PutnamHancock

Wyandot

Marion

Delaware

Seneca

Sandusky

Ottawa

Lucas

Wood Erie

Huron

Holmes

Guernsey

Perry MorganNoble

Belmont

Harrison

Clermont

Jefferson

RichlandCrawford Ashland

Montgomery

Lower Northeast

Central

Southeast

Upper Northeast

Southwest

Northwest

Trauma-Informed CareRegional Collaboratives

SAMHSA’s Definition of Recovery

Recovery is a process of change through which

individuals improve their health and wellness, live a

self-directed life, and strive to reach their full

potential.

Slide 44

Recovery

• Allow patients to save themselves• Remember what your role is• Not a savior or rescuer• Facilitator, support• Help reinstate renewed control• The more helpless, dependent and

incompetent the patient feels, the worse the symptoms become

Slide 45

What we CAN do . . .

Slide 46

• Treat everyone with universal precaution: Assume that the person has experienced trauma even if you don’t know their personal history.

• Create a welcoming environment that promotes a feeling of safety and non-violence – pay attention to physical space, tone of voice, loudness of music or side conversations and eliminate anything that could be intimidating or anxiety provoking.

• Be very aware of personal space. Realize that some painful memories may be triggered by touching, hugging, behaving authoritatively, standing over the person or blocking their exit in a closed space, etc.

What we CAN do . . .

Slide 47

• Recognize that certain practices (e.g., seclusion and restraint) may create trauma and trigger traumatic memories. Make a commitment to non-violence in words, actions and policy/practices.

• Support meaningful power-sharing and decision-making –Voice and Choice!

• Use tools/approaches that help calm fear/anxiety/anger/defensiveness as a preventative and healing method rather than engaging in confrontational approaches that focus on coercion or control of external behavior.

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Putting it all together

First ask, “What happened to you?”

Then, support in 4 difficult sentences:

1. I believe you. 2. Thank you for trusting me enough to tell me. 3. I am sorry that happened to you. 4. I support you whatever you choose to do.

Then, listen and be present. And then, listen and be present some more.

• You’ll experience an urge to take care of the person. That’s normal, because you care. But you must, must, must sit still with it and let the person take care of herself or himself. • Trauma is (in part) about having control over your body and your choices taken away. Survivors need safe environments where they can take back control. So, sit still with your need to drive them to the hospital, call the police, beat the shit out of the perpetrator, or even hug the survivor. Sit still, notice that you care, be kind to yourself, and sit still some more. • You have given the greatest gift you can give; yourself. Your caring attention. • And then go take really good care of yourself!

Things to Remember

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Video: Power of Empathy

OhioMHAS Trauma Clearinghouse Website mha.ohio.gov/traumacare

Dr. Mark Hurst, M.D., FAPAMedical Director, OhioMHAS

30 East Broad Street, 36th Floor, Columbus, OH 43215

(614) 466-6890Mark.Hurst@mha.ohio.gov

Tina EvansRegional Liaison Team Lead, Ohio

Department of Developmental Disabilities

30 East Broad Street, 12th Floor, Columbus, OH 43215

614.752.9028tina.evans@dodd.ohio.gov

Joey SupinaExecutive Director

Sandusky Artisans Recovery Community Center

419-621-9377 joeysupina@aol.com

Kim KehlTIC Project Coordinator, Office of

the Medical DirectorOhioMHAS

30 East Broad Street, 36th Floor, Columbus., OH 43215

(614) 644-8442Kim.kehl@mha.ohio.gov

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