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Trauma Informed Care: Theory & Pactice with Laurie Robinson
Trauma Informed Care: Theory & Pactice with Laurie Robinson
Trauma Informed Care: Theory & Pactice with Laurie Robinson
Trauma Informed Care: Theory & Pactice with Laurie Robinson
Trauma Informed Care: Theory & Pactice with Laurie Robinson
Trauma Informed Care: Theory & Pactice with Laurie Robinson
Trauma Informed Care: Theory & Pactice with Laurie Robinson
Trauma Informed Care: Theory & Pactice with Laurie Robinson
Trauma Informed Care: Theory & Pactice with Laurie Robinson
Trauma Informed Care: Theory & Pactice with Laurie Robinson
Trauma Informed Care: Theory & Pactice with Laurie Robinson
Trauma Informed Care: Theory & Pactice with Laurie Robinson
Trauma Informed Care: Theory & Pactice with Laurie Robinson
Trauma Informed Care: Theory & Pactice with Laurie Robinson
Trauma Informed Care: Theory & Pactice with Laurie Robinson
Trauma Informed Care: Theory & Pactice with Laurie Robinson
Trauma Informed Care: Theory & Pactice with Laurie Robinson
Trauma Informed Care: Theory & Pactice with Laurie Robinson
Trauma Informed Care: Theory & Pactice with Laurie Robinson
Trauma Informed Care: Theory & Pactice with Laurie Robinson
Trauma Informed Care: Theory & Pactice with Laurie Robinson
Trauma Informed Care: Theory & Pactice with Laurie Robinson
Trauma Informed Care: Theory & Pactice with Laurie Robinson
Trauma Informed Care: Theory & Pactice with Laurie Robinson
Trauma Informed Care: Theory & Pactice with Laurie Robinson
Trauma Informed Care: Theory & Pactice with Laurie Robinson
Trauma Informed Care: Theory & Pactice with Laurie Robinson
Trauma Informed Care: Theory & Pactice with Laurie Robinson
Trauma Informed Care: Theory & Pactice with Laurie Robinson
Trauma Informed Care: Theory & Pactice with Laurie Robinson
Trauma Informed Care: Theory & Pactice with Laurie Robinson
Trauma Informed Care: Theory & Pactice with Laurie Robinson
Trauma Informed Care: Theory & Pactice with Laurie Robinson
Trauma Informed Care: Theory & Pactice with Laurie Robinson
Trauma Informed Care: Theory & Pactice with Laurie Robinson
Trauma Informed Care: Theory & Pactice with Laurie Robinson
Trauma Informed Care: Theory & Pactice with Laurie Robinson
Trauma Informed Care: Theory & Pactice with Laurie Robinson
Trauma Informed Care: Theory & Pactice with Laurie Robinson
Trauma Informed Care: Theory & Pactice with Laurie Robinson
Trauma Informed Care: Theory & Pactice with Laurie Robinson
Trauma Informed Care: Theory & Pactice with Laurie Robinson
Trauma Informed Care: Theory & Pactice with Laurie Robinson
Trauma Informed Care: Theory & Pactice with Laurie Robinson
Trauma Informed Care: Theory & Pactice with Laurie Robinson
Trauma Informed Care: Theory & Pactice with Laurie Robinson
Trauma Informed Care: Theory & Pactice with Laurie Robinson
Trauma Informed Care: Theory & Pactice with Laurie Robinson
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Trauma Informed Care: Theory & Pactice with Laurie Robinson

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  • First, this presentation is about the theory and practice of trauma-informed care or services.Let me tell you what it will not do first…It will not cover any detail on therapeutic interventions, or how to treat people who have experience trauma. I’ll mention some treatment approaches but we’re going to stick to leaning what being a trauma-informed service system is and maybe even about being trauma-informed as an individual working with people, but this presentation is not about the provision of therapy. (Missing Pieces Report – put together wy CPC in Waterloo refers to training more truama-informed counsellours.) You can be trauma-informed and not do trauma therapy. And that is the key to this presentation. Second, for the most part, I refer a lot to trauma in young children to illustrate the concepts in the theory. Just the same, the theory is not necessarily about a specific population of children or adults, but …it is more about how we view the lives and experiences of all human beings we see in our work.Last, the presentation is really about changing our mistaken beliefs about the people we serve in our work, it’s about a shifting paradigm in the field that is based on new research and developments in this field that have only begun to take hold over the last 15 to 20 years. Some in the field are calling it cutting edge, but it’s been percolating for years. Especially in the US. It’s finally coming to Canada, the UK, Australia. believe really that it’s time has come…and it’s about time!So, what I hope you will take from this presentation is new knowledge about the prevalence of trauma in our society, how trauma affects brain development and later functioning, how it affects our health, and most especially I hope you take away an beginning understanding of what it means to be trauma-informed as and individual working with people and most especially as a system of services working together to help people survive and thrive no-matter what sector we work in.
  • A bit of background on kidsLINK’s work.Brief introduction to a definition of trauma…there are many.Brief review of the research – the prevalence research mostly, with attention to cross sectors of what I call “vulnerable populations”Define the difference between Trauma Informed vs. Trauma Specific servicesAn introduction to the science of Trauma Informed Care. A overview of what is happening in the US and Canada in trauma informed care. Questions to consider?How might a system of trauma-informed services improve the lives of children, youth and families you work with? How might this approach have an affect on prevention, early intervention, effective treatment/intervention, rehabilitation vs. incarceration?What can you do to ensure you are truama-informed?
  • kidsLINKsaw children coming from across the province with some of the most serious trauma backgrounds we had ever seen. More and more we were seeing children who never slept, couldn’t learn, were anxious, depressed, self harming and obviously severely traumatized. We were concerned about the rise in medications we were dispensing to children and becoming disillusioned and losing hope for our children’s futures. Physical restraints and staff injuries were increasing, and staff morale was low. A small group of staff formed a committee to look at Complimentary and Alternative Methods of practice. We wanted to increase the use of relaxation techniques, Yoga for kids, imagry and visualization etc. And this led us to the TI literature. By 2007 reading and researching the Trauma Informed Systems of Care literature…and it was like a light bulb went off….truly!!! The timing was perfect for us….we took our quest to the board and together we set a strategic priority to shift our practice to be completely “trauma informed”. 2009 travelled to Maine and New York 2009 Education of others approved by the Board – on TI Systems of Care 2010 sent 15 people to Sanctuary training in New York. Designed a 3 phase research study on the implementation and outcomes of the SM Trained all kidsLINK staff over 2010 and 2011 kidsLINK hired me to develop and deliver presentation to community partners and beyond.Before we get into the details lets get on the same page with a definition of trauma
  • There are numerous variable definitions out there, but for our purposes at kidsLINK we chose one that includes more explanation than some…it just worked for our purposes.Recently community stakeholders especially child welfare sector have added frequent moves, separations or losses. Some have argued for the addition of frequent repeated bullying including cyber bullying. The main issue here is that the person experiences the incident/incidents as extremely frightening and threatening. Trauma can interfere with a child’s ability to think and learn.Recent studies have even documented how exposure to trauma can interfere with the healthy development of the brain. (talk about that a little later)The long-term consequences may include substance abuse, poor school performance, mental health disorders, and physical health conditions. Traumatized children and youth may lose much their capacity to manage and control their emotions and may suffer from trauma-induced mood changes, irritability, depression, and anger that not only are disabling for them but are profound challenges for families and communities. Their capacity to form healthy emotional relationships may be severely diminished, and tragically, the consequences of trauma may affect future generations as traumatized children and youth grow to adulthood and become parents” Children and Trauma in America: A Report of the National Child Traumatic Stress Network (2004)
  • Of course, there is variability in responses to Traumatic Events or Adverse Events…There is a quote I use from Darby…that is quite simply put…As one would expect….the impact of the adverse event….depends on several factors…“It is not the event that determines whether something is traumatic, but the individual’s experience of the event” (Darby et al., 2008, p.17).
  • As one would expect….the impact of the adverse event….depends on several factors…What is the age and developmental stage of the child….?The is the child’s perception of the danger faced by the vent?Consider whether the child was the victim of an adverse event or a witness to an adverse eventThe child’s relationship to the victim or perpetrator is also very important to considerWhat is the child’s past experience with trauma, is this a repeat of a traumatic eventWhat are the adversities the child faces following the trauma? Were there protective factors/resources The presence/availability of adults who can offer help and protection (again, a protective factor…)
  • Epidemiology - The scientific and medical study of the cause and transmission of disease within a population Prevalence – occurring, accepted or practiced commonlyThis is only a brief review of the research….which is plentiful on the cause and prevalence of child trauma… We’ll look at General Population StudiesSpend more time on studies of “Vulnerable Populations” what I call them…We will not review Disaster Studies – There is just not enough time!
  • This is probably the most important study that has ever been done of Trauma! Study conducted in the 1990s by Drs. Felitti and Anda as a collaboration between Kaiser Permanente (a large health maintenance organization) and the Centers for Disease Control, a branch of the Federal government.
  • Surveyed over 17,000 adults - looked at the relationship between adverse childhood experiences (ACEs) and later health outcomes in adults. What they found was some very disturbing data that tells us that traumatic experiences in childhood have a strong relationship with poor physical, mental and social health in adulthood.
  • It also demonstrated how pervasive early childhood adversity is in our society and how widespread exposure to trauma and adversity isThe ACE study found that the presence of four or more serious adverse experiences during childhood greatly increased adults’ risk for alcoholism, drug abuse, suicide attempts, sexually transmitted diseases, and poor general health.67% reported at least 1 exposure to ACEUsing the Harm Standard incidence numbers from NIS-3, the total annual direct and indirect cost of child abuse and neglect has been estimated at $94 billion (Fromm, 2001). The daily cost of childhood abuse and neglect is estimated to be $258 million (Pelletier, 2001).
  • Exposure to trauma in early childhood has long lasting effects because it alters the course of the child’s normal development and therefore can change the structure of the brain.Human brains do most of their development after birth, making us vulnerable to the effects of early disruptions and traumatic experiences.Human brains are also incredibly malleable – experiences shape the brain’s development even more than genetics, meaning that trauma can change the brain’s structure while it is still growing.The rapid growth that happens in early childhood also leaves humans vulnerable to the realignment of neurons
  • When a child is exposed to chronic stress or continued crisis, the brain is flooded with stress hormones, creating a state of “chronic hyperarousal”, Effects of Emotional Trauma on the BrainDuring a stressful event, the sympathetic nervous system activates the fight-or-flight response. The stress hormone cortisol is released. Normally, when the stressor goes away, the parasympathetic nervous system responds and returns the body to normal. However, in a traumatic event, which is caused by unusually large amounts of stress, excess cortisol is released in the body. That large amount of cortisol has negative effects on the brain, causing damage to the neurons. (Nixon, Nishith and Resick).
  • The biology of soul murder: Fear can harm a child's brain. Is it reversible? (Nov. 11, 1996). U.S. News & World Report As you’ve heard, Cortisol a key hormone involved in the body’s response to stress, both physical and emotional. Cortisol increases blood sugar levels, increases blood pressure, and suppresses the immune system, which is part of the body’s fight-or-flight response that is essential for survival. Adrenaline production increases your alertness and energy level, also increasing your metabolism by helping fat cells to release energy. Cortisol has widespread actions which help restore homeostasis after stress, including increasing production of glucose from protein to quickly increase the body’s energy during stressful times. But……Excess cortisol leads to damage in a brain region (known as the hippocampus), causing memory lapses, anxiety and an inability to control emotional outbursts.Cortisol and other brain chemicals also can alter brain centers that regulate attention, affecting a child's capacity to attend to words on the blackboard instead of a jackhammer banging outside.
  • Studies in vulnerable populations are also plentiful…
  • There is a great deal of research on the prevalence of trauma in vulnerable populationsToo much to review here! Those that identify as having experienced abuse, neglect and sexual abuse.
  • Up to 50%, many feel is a conservative number. By the time most children enter the child welfare system, they have already been exposedto a wide range of painful and distressing experiences, many of which remain unknown andunreported during intake. Foster placement often separates a child from what is familiar andbeloved (primary caregivers, family members, friends, home, community, school). In addition,children in the child welfare system typically face many other sources of ongoing stress thatcan challenge child welfare workers’ abilities to intervene. These include:PovertyRacism and other forms of discriminationSeparations and frequent movesSchool problemsGrief and lossRefugee or immigrant experiencesStudy of children in foster care revealed - PTSD was diagnosed in 60% of the sexually abused children and in 42% of the physically abused children (Dubner & Motta, 1999)18% of the foster children (with no known history of sexual or physical abuse) still met criteria for PTSD, - result of exposure to domestic or community violence (Marsenich, 2002)
  • Trauma is a major contributing factor to the development of co‐occurring disorders in young people. In addition, young people who use drugs and alcohol put themselves at risk for further trauma and complicate assessment and treatment.ACE study finding - five or more adverse events, the likelihood of illicit drug use increased 7- to 10-fold.Teens who have experienced physical or sexual abuse or assault were three times more likely to report past or current substance abuse than those without a history of trauma (Kilpatrick, et.al. 2003)
  • When it is Misdiagnosed:Often results in a diagnoses of depression, anxiety, ADHD, bipolar, OCD, ODD, CD etc. Symptoms of these disorders greatly overlap with the symptoms of PTSD and trauma.New York State Office of Mental Health - only 1 in 200 adult inpatients and only 1 in 10 child/adolescent inpatients carried either a primary or secondary diagnosis of PTSD. Failure to recognize - leads to prolonged hospitalization and exclusion from participation in Trauma specific services in community settings. Tucker, 2002How do you know trauma, diagnosis behaviour etc? There are ass’ts that assist us in differentiating between these diagnoses and trauma, but unresolvedtrauma typically contributes to the development of mental health issues.Trauma symptoms can also be misinterpreted as “behaviour”- e.g. bedtime, not paying attention in school (distractions bec of hypervigilence, constant scanning etc.), unpredictable for-no-reason aggression to adults and peers bec trauma triggers not understood (e.g. hand on shoulder or back startles child)By being a trauma informed organization, we can help prevent this from happening….So what is “Trauma informed”?
  • Just as the physiology of the brain is impacted by physical trauma – it is equally so affected by severe emotional trauma.Biomedical and epidemiological research shows childhood abuse and trauma to have profound and enduring effects on the brain and nervous systems, on perceptions of self and others, and to be the root cause of many of the most serious and chronic health, behavioral health and social problemsChildhood trauma is of epidemic proportions . Needs to be addressed as major public health issue.Yet, Childhood trauma is often unrecognized, ignored or denied. There is great resistance to this reality and very little action in response to it.“Time does not heal – it conceals”The human costs of failure to address childhood trauma are high.There are many many faces of unaddressed childhood trauma – and many paths the impacts of such trauma can travel. Behind each one of these faces, there is an abused and traumatized child who never was seen or heard or responded to with the kind of protection and help he or she needed. Each one of these individuals has a story to tell – a story they often may have tried to tell, but no one listened, or believed, them.This is what we must change. We must begin asking What happened to instead of what wrong with – these individuals.Until we as a society address by prevention and early intervention the abuse and traumatization of children, violence toward self and others will continue. And will be passed on from generation to generation.
  • Trauma-specific services are designed to treat the actual consequences of trauma. *Examples of TS treatments: Trauma focused cognitive behaviour therapy (TF CBT)-all clinicians in our agency full trained in the model (3 day training, on line, book, regular consultations with trainer for over 2 yrs) Eye Movement Desensitization and Reprocessing (EMDR)TF CBT and EMDR are considered the gold standard for trauma treatment according to the latest researchIntergenerational trauma treatment model (ITTM) (is now EBP)Emotional Feedom Technique (EFT)Limitations and challenges we have experienced-few EBP TS treatment models for young children (2-5)Bruce Perry’s NMT would add that to heal, therapeutic interventions must activate those portions of the brain that have been altered by the trauma. MORE ON THIS LATER
  • 2008 – Dare to Transform people working to implement trauma-informed care shared best practices and explored innovative strategies for organizational change.
  • A Trauma Informed organization is one that has made a commitment to practices, policies and a culture that requires staff at all levels and in all roles to modify what they do based on an understanding of the impact of trauma and the specific needs of traumatized individuals (Thrive, Trauma Informed System of Care, Portland, Maine).Symptoms are seen as adaptations-how the person coped with the trauma. Understanding this can lead to a change in culture and environment-to reduce the likelihood of re-traumatizing a client.
  • Two major tenets!System wide approach – a paradigm shift from where we are today….SAMSHA - National Center for Trauma-Informed Carehttp://www.samhsa.gov/nctic/default.aspTwo major characteristicsWhen a human service program takes the step to become trauma-informed, every part of its organization, management, and service delivery system is assessed and potentially modified to include a basic understanding of how trauma affects the life of an individual seeking services. Trauma surviviors – now called people with lived experience of trauma
  • This can go for the criminal justice setting too.
  • It is about what happened to you…NOT…what is wrong with you!
  • Because Trauma-Informed Theory is systems, organization, and individual approach the criteria crosses all Macro, Mezo, and Micro work. (It you’re into ecological systems theory)
  • Substance Abuse and Mental Health Services Administration funded a project
  • Refer to handout…the Canadian Approach *The “Canadian Approach” by Laurie Robinson, adapted from A Closer Look, Trauma Informed Treatment in Behavioral Health Settings, Ohio Legal Rights Service, 2007#1 - Trauma Function and Focus in state mental health department? 32 states in 2008MAINE – the State department of Children’s Behavioural Health Services teamed with Maine’s leading mental health service provider to fund the “Thrive Initiative” a 9 million project. Thrive was the first Trauma Informed System of Care for children youth and families in the nation. Trains organizations, cross sectoral – for system transformation. And successfully advocated for State funding for services to be tied to meeting criteria for delivering trauma informed care. #2 - Oregon - State trauma policy or position paper. 15 States. Oregon – State Policy on TI Care. “It is the policy of the Addictions and Mental Health Division (AMH) of the Oregon Department of Human Services that all state and community providers, and those who oversee public mental health and addiction services are informed about the effects of psychological trauma, assess for the presence of symptoms and problems related to that trauma, and develop and offer services that facilitate recovery in accordance with Oregon Administrative Rules.”
  • #8 - Colorado - Policies, procedures, rules, regulations and standards to support access to trauma treatment, to devleop trauma informed service systems and to avoid re-traumatization. 33 StatesColorado - Program policies and procedures shall recognize the interplay between substance use disorder and trauma symptoms because of the very high prevalence of trauma among this population.1155274 a. Program policies and procedures shall reflect an understanding of the effects of traumatic experiences and the unique vulnerabilities of trauma survivors so that re-victimization and misdiagnosis do not occur.1155275 b. Decisions about the course of treatment shall be considered with the understanding of the way symptoms of trauma shall affect treatment participation, progress in treatment, and the relationship between the program and the client.1155276 c. Symptoms of trauma shall be understood to include dissociation, flashbacks, feelings of being unsafe, reluctance to participate in social or group activities, and/or pervasive or situational sadness or hopelessness.1155277 d. Program services shall directly address trauma issues currently manifesting in the client’s life.Assessment Rules - Symptoms and/or behavior that can be attributed to exposure to trauma. If delayed for clinical reasons, the expected date of this assessment shall be documented in the client record;Too many to review!
  • Needs assessment, evaluation, and research to explore prevalence and impacts of trauma, assess trauma sirvivor satisfaction, service utilization and needs, and to monitor and make adjustments in trauma-informed and trauma specific service approaches. Universal trauma screening and assessment.Trauma informed services and service systems.Trauma Specific Services, including evidence-based and promising practice treatment models.
  • Released in November of 2011 SAMSAH’s Strategic Plan8 Strategic Initiatives. #1 Prevention “Trauma is strongly associated with mental and substance use disorders!
  • New York's Office of Children and Family Services (OCFS), which runs the state's juvenile placement system, adopted Sanctuary in 2007 to establish a more therapeutic environment within its facilities.The Sanctuary ModelBeginning in early 2007, OCFS adopted the Sanctuary Model to establish a more therapeutic environment within its facilities. Developed by Dr. Sandra Bloom in the early 1990s, Sanctuary is a systems approach for creating or changing organizational culture in order to more effectively heal and address trauma. Key components of the model include a commitment to nonviolence, open communication, social responsibility, and growth and change. Implementing Sanctuary requires two years of intensive staff training and leadership development. While Sanctuary has been applied in a number of settings to date, including acute care mental health facilities, OCFS’s use of this model is the first attempt to implement it in a juvenile justice system. OCFS has staggered its implementation of Sanctuary: staff at 20 facilities have been trained in the model since January2007, and the approach will be fully rolled out across the systemby 2012. Currently, the OCFS Bureau of Evaluation and Research isconducting an evaluation of the Sanctuary program at nine stateoperatedand private facilities, which will document the implementationprocess and examine whether this approach is associated with positivechanges in facility climate, safety, and behavior of youth and staff.S sourceOffice of Children and Family Services, An Introduction to the Sanctuary Implementation Process(New York: Office of Children and Family Services, February 2009).
  • Tim Wall – ED Very good toolkit, generic. Provincial govt announced funding for Klinic to establish a Trauma Resource Centre .  This will include development of a virtual resource centre and will allow us to expand our efforts to promote trauma informed care and practices both provincially and nationally, develop a trauma knowledge exchange centre and continue to develop resource material and new training modules including a train the trainer program.   Entered into a conversation with the Mental Health Commission of Canada to develop an online community of practice for trauma. 
  • Nancy Poole – Produced an excellent Toolkit for implementing Trauma Informed Care into services for girls and women in the area of substance use.
  • Or hire a trauma specialist…Thanks you!
  • Transcript

    • 1. Psychological TraumaThe Case For the Development ofTrauma-Informed Service Systems Laurie Robinson, MSW
    • 2. Agenda1. Setting the Stage – the kidsLINK Project2. Define Trauma3. The Research and Rationale for TI system4. Trauma Informed vs. Trauma Specific5. What’s Happening in North America6. The 12 Criteria for a Trauma Informed System
    • 3. Setting the Stage• 2002 - Children with serious and complex needs• 2006 - Began exploring complimentary & alternative methods – led to TI literature• 2007 – Began strategic planning process with the Board• 2008 – Linking Research, Training & Practice• 2009 -2012 Implement Trauma Informed Services
    • 4. What is Trauma?“Trauma is an emotional wound resultingfrom a shocking event or multiple andrepeated life threatening and/or extremelyfrightening experiences that may cause lastingnegative effects on a person, disrupting thepath of healthy physical, emotional, spiritualand intellectual development.”Children and Trauma in America: A Report of the National Child TraumaticStress Network (2004)
    • 5. Variability in Responses toStressors and Traumatic EventsThe impact of a potentially traumatic event is determinedby both: • The objective nature of the event • The person’s subjective response to itSomething that is traumatic for one person may not betraumatic for another.
    • 6. The impact of a potentially traumatic event depends on several factors1. Age and developmental 5. Past experience with stage trauma2. Perception of the danger 6. Adversities faced faced following the trauma3. Victim or witness 7. Presence/availability of adults who can offer help4. Relationship to the victim and protection or perpetrator
    • 7. Epidemiologyand Prevalence ofTrauma What we have learned
    • 8. General PopulationStudiesAdverse ChildhoodExperiences (ACE) study (1998)Examined the cumulative effects ofmultiple adverse childhoodexperiences on physical and mentalhealth.Felitti and Anda (1998)
    • 9. What is the Adverse ChildhoodExperiences (ACE) Study? • 10 year study • 17,000 people involved • Looked at effects of adverse childhood experiences over the lifespan • Largest study ever done on this subject
    • 10. Adverse Childhood Experiencesare CommonOf the 17,000 who participated:• 1 in 4 exposed to 2 categories of ACEs• 1 in 16 was exposed to 4 categories• 22% were sexually abused as children• 66% of the women experienced abuse, violence or family strife in childhood
    • 11. The Psychobiologyof Trauma“Our brain helps ussurvive and thrive whilewe develop” Bruce Perry, M.D., Ph.D. Child Trauma Academy
    • 12. It Begins With Fear• Faced with a threat, the body embarks on a cascade of physiological reactions.• Adrenalin surges, setting the heart pounding and blood pressure soaring and readying the muscles for action, a response called "fight or flight."
    • 13. Trauma Altersthe BrainIncreasing evidence suggests that inabused or neglected children, thissystem goes awry, causing a harmfulimbalance of cortisol in the brain.
    • 14. Vulnerable Population Studies
    • 15. Vulnerable PopulationsThere is a great deal of research on the prevalence oftrauma in vulnerable populations of children and youthChildren and youth whoare… • Intellectual • Mental Health• Abused and Disabilities • Child Welfare Neglected • Aboriginal • Homeless Youth• Sexually Abused Decent • Youth Justice• Self Injurious / • Refugees Suicidal • Lesbian and Gay• Substance Using Youth (LGBTQ)
    • 16. Mental Health• 51 – 98% of public mental health clients with severe mental illness, including schizophrenia and bipolar disorder, have been exposed to childhood physical and/or sexual abuse.• Most have multiple experiences of trauma (Goodman et al., 1999, Mueser et al., 1998; Cusack et al., 2003). 17
    • 17. Child Welfare• More than 95% suspected.• 75% experienced moderate to major event. (Griffin et.al, 2011)
    • 18. Youth Justice• 75% - 93 % of youth entering the system have experienced trauma (Justice Policy Institute, July 2010) 19
    • 19. Substance Use • 67% of people in substance use treatment report histories of childhood abuse and neglect (National Association of State Mental Health Program Directors, 2005).
    • 20. What does the prevalence data invulnerable populations tell us? • Trauma is Epidemic • Victims of trauma are found across all sectors of care 21
    • 21. Trauma isoften … • Misdiagnosed • Misinterpreted “Trauma is often unrecognized, ignored or denied” (Jennings, 2008)
    • 22. “As awareness of the prevalence and impacts oftrauma increases [those individuals affected] areincreasingly viewed not as a subgroup oranomalous population of clients, but asencompassing nearly all children, adolescentsand adults served by public mental health andsubstance abuse service systems” (p. 3)Models for Developing Trauma-Informed Behavioral Health Systemsand Trauma Specific Services (2008)
    • 23. In SummaryChildhood abuse and trauma: • Causes serious and chronic health, behavioral health and social problems • Impacts brain and nervous system, perception of self and others • Epidemic proportions – a major public health issue • Often unrecognized, ignored or denied (Jennings, 2004)
    • 24. Trauma-Informed is MUCH more that trauma treatment! There is an important difference between “Trauma Informed” care and delivering “Trauma Specific” treatment. 25
    • 25. Trauma SpecificTreatmentA trauma specific service isdesigned to treat the “actualsequelae” of traumaHarris, M., Fallot, R., 2001E.g. Trauma Focused Cognitive BehaviourTherapy
    • 26. The Science ofTrauma Informed Services 27
    • 27. Roots in the United States• 2001 – 12 States formed and informal network – State Public System Coalition on Trauma (SPSCOT) – Formed a listserv for ongoing communication• 2004 - Produced “Trauma Services Implementation Toolkit for State Mental Health”. (Jennings, 2004) 28
    • 28. Roots in the United States• 2004 – Dare to Act Conference (National)• 2005 – National Centre for Trauma Informed Care formed.• 2007 – Update to the toolkit (SAMHSA)• 2008 - Dare to Transform Conference,
    • 29. “Trauma Informed” - Definition…means that individuals in organizationsare educated on the causes and effects oftrauma and understand the potential toretraumatize individuals by providingservices and/or interacting in a mannerthat is not sensitive to their experiencesand needs.(Thrive, Trauma Informed System of Care, Portland, Maine)
    • 30. Trauma Informed Organizations1. Every part of a TI organization, its management, and service delivery system is assessed and potentially modified to include a basic understanding of how trauma affects the life of an individual seeking services.2. The whole organization understand 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. Substance Abuse And Mental Health Services Administration (SAMHSA)
    • 31. Trauma Informed Philosophy “Trauma-informed strategies ultimately seek to do no further harm; create and sustain zones of safety for children, youth and families who may have experienced trauma; and promote understanding, coping, resilience, strengths-based programming, growth and healing.” (Cooper, Masi, Dababnah, Aratani and Knitzer, 2007; Strengthening Policies to Support Children, Youth and Families Who Experience Trauma, National Centre for Children in Poverty, Columbia University, pg. 17)
    • 32. Universal Precautions as aCore Trauma Informed Concept Presume that every person in a treatment setting has been exposed to abuse, violence, neglect or other traumatic experiences
    • 33. Re-examination “What “What is happened wrong with to you?” you”
    • 34. 12 Criteria
    • 35. “Blueprint for Action” Jennings, 2007 • State Accomplishments, Activities and Resources Toward Meeting Criteria for Building Trauma Informed Mental Health Service Systems • Reviewed action across the U.S. • 12 Criteria
    • 36. 12 Criteria1. A designated trauma function and focus in the state mental health department.2. State trauma policy or position paper.3. Workforce recruitment, hiring and retention.4. Workforce orientation, training, support, competencies and job standards related to trauma.Ann Jennings, 2008 Update, Models for Developing Trauma-InformedBehavioural Health Systems and Trauma Specific Services, NationalCentre for Trauma Informed Care, funded by SAMHSA
    • 37. 12 Criteria5. Consumer/Trauma Survivor/Recovering person involvement and trauma informed rights.6. Financing criteria and mechanisms to support development of trauma-informed service systems and implementation of evidence based and promising practice trauma treatment models and services.7. Clinical practice guidelines for working with children and adults with trauma histories.8. Policies, procedures, rules, regulations and standards to support access to trauma treatment, to develop a trauma- informed system, and to avoid re traumatization.
    • 38. 12 Criteria con’t9. Needs assessment, evaluation, and research to explore prevalence and impacts of trauma; assess trauma survivor satisfaction, service utilization and needs; and to monitor and make adjustments in trauma-informed and trauma-specific service approaches.10. Universal trauma screening and assessment.11. Collaborations amongst trauma-informed services and service systems.12. Trauma-specific services, including evidence based and promising practice treatment models.
    • 39. Toolkits• Trauma Services Implementation Toolkit for State Mental Health (2004)• Child Welfare Trauma Training Toolkit (2008)• Child Trauma Toolkit for Educators (2008) National Child Traumatic Stress Network• Toolkit for Refugees (2010) Centre for Refugee Trauma and Resilience• Trauma-Informed Organizational Toolkit for Homeless Services (2010) The National Centre on Family Homelessness Search “trauma informed toolkit” www.kidslinkcares.com
    • 40. Substance Abuse and Mental Health Services Administration (SAMSHA)Strategic Initiative #2 Trauma and Justice• Overview: Reducing the pervasive, harmful, and costly health impact of violence and trauma by integrating trauma- informed approaches throughout health, behavioural health, and related systems and addressing the behavioural health needs of people involved in, or at risk of involvement in the criminal and juvenile justice system.
    • 41. Canada
    • 42. kidsLINK - Ontario• 2009 - Visit Thrive (Maine), Andrus/Sanctuary (New York)• 2009/10 Explore/implement trauma specific service - TFCBT• 2010 – Implement universal trauma screen at Front Door (Joint Initiatives)• 2010 – 2013 Implementation of the Sanctuary Model
    • 43. Klinic – ManitobaRecently announced fundingfor a Trauma Resource CentreAdvocating with MentalHealth Commissionof Canada for NationalResources
    • 44. British Columbia Centre of Excellence for Women’sCoalescing on Women and SubstanceUse: Trauma-informed Online Tool Health
    • 45. “I have come to believe that traumais the problem and substance usethe solution…until the solutionbecomes the problem”Addictions Counselor
    • 46. Where to Go From Here?Service Providers Policy Makers & Funders Develop a “trauma team”  Create regional/province Seek and share up to date wide standing Trauma Task research and knowledge Force Collaborate with others on  Develop a written policy on training and building Trauma Informed Service awareness (seek training!) System Implement a universal trauma screen (or refer)  Establish a clearly identified Conduct thorough trauma Trauma Office in assessments on admission government (or partner)  Coordinate Trauma Offer trauma specific Informed Treatment treatments (refer and Services across Ministries partner)
    • 47. Thank You!Contact InformationFor further information on trauma informed service systems work,please contact: Barb Ward, MSW, RSW – Director of Services, kidsLINK bward@kidslinkcares.com Laurie Robinson, MSW, Consultant, kidsLINK lrobinson@kidslinkcares.com; laurie_robinson@rogers.com

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