Client-Centered andTrauma-Informed Services Deborah Werner Pat Tucker Advocates for Human Potential, Inc, This presentation is made possible with support from the Substance Abuse and Mental Health Services Administration
The importance of a home • Place to be • Stability • Security/safety • Control • “Stuff” • Responsibility When you don’t have these things what happens?
Homelessness is often not thefirst experience of trauma and uncertainty in a homeless mother’s life.
Trauma among mothers who are homeless: • Over their lifetime, 92% experienced severe physical and sexual assault. • 25% experienced random violence. • 66% experienced severe physical violence as children. • 43% were sexually molested as children. Bassuk EL, Weinreb L, Buckner J, et al. (1996). The characteristics and needs of sheltered homeless and low-income housed mothers. JAMA, 276(8): 640-646.
Trauma can come from many things • Emotional, sexual or physical abuse • Natural disaster/fire • Physical attack/ abuse/ threats • Life-threatening accident, catastrophic injuries and illnesses • Witnessing injury/death • Combat • Family separation • Extremely painful and frightening medical procedures Photo: h.koppdelaney @ flicker.com • Rape or assaultAccompanied by feeling of • Domestic violenceintense fear, helplessness,or horror.
Definition of TraumaThe diagnostic manual used by mental healthproviders (DSM IV-TR) defines trauma as,“involving direct personal experience of an eventthat involves actual or threatened death orserious injury, or other threat to one’s physicalintegrity; or a threat to the physical integrity ofanother person; or learning about unexpected orviolent death, serious harm, or threat of death orinjury experienced by a family member or otherclose associate. American Psychiatric Association [APA] (2000, p 463)
Definition of Trauma (cont.) “The person’s response to the event must involve intense fear, helplessness or horror. …or in children, the response must involve disorganized or agitated The behavior.” disturbance causes clinically significant distress or impairment in social, occupational, American Psychiatric Association [APA] or other (2000, p 463)important areas of functioning.
Common Symptoms (DSM IV-TR, 2000)• Dissociation/freezing • Numbing of responsiveness• Flashbacks • Depression• Hyper-vigilance • Substance abuse• Terror • Upsetting reminders and• Anxiety triggers• Self-injury• Eating problems• Sleep disturbances or nightmares• Fight or flight response alarm reaction followed by intense fear Photo: will fisher @ flickr.com
The Impact Continues Trauma begins a complex pattern of actions and reactions that have a continuing impact over the course of one’s life.
A victim’s world view Relationships are characterized by victim - victimizer dynamic. Someone is the controller and someone controls. This world view is carried through all relationships Francine Feinberg, MetaHouse, Incincluding social services and employment.
The Internal Working Model• The world is a frightening place – Shouldn’t trust others – Feels vulnerable– Misreads cues – Under-reacts to real danger – Over-reacts to innocent exchanges Photo: aryche @ flicker.com Francine Feinberg, MetaHouse, Inc
The Internal Working Model• No ability to affect the situation. – Actions bring disappointment, retribution – Hostility – Anger, Attitude – Passivity – May as well not try – Bad things will happen and no one will protect her – Fear, anxiety Photo: aryche @ flicker.com – Self-protective hostility Francine Feinberg, MetaHouse, Inc
Men React Differently to Trauma• This is an emergency! – “Fight or flight” : men may be aggressive, antisocial, or “on guard” – Boys may “act out,” use substances, or be truant• Better keep this quiet. – Boys and men are less likely to talk it out or admit fear.• Being a man means appearing strong. Hodas (2006), Responding to Childhood Trauma – Males may feel shame that they could Mejia (2005), Gender Matters: Working with Adult Male Survivors of Trauma not defend themselves.
Trauma can be self-defining• Sense of self• Sense of efficacy• World view• Coping skills• Relationships with others• Ability to regulate emotions• How one approaches services• How one approaches the culture of the treatment agencies, work environments, and life in general Francine Feinberg, Meta House, Inc
3 Stages of Trauma Recovery • Safety • Mourning • Reconnection Judith Herman Our focus today is on safetyPhoto: Andy and Becky’s email@example.com
Trauma-Informed Approaches• Based on current literature and informed by research and effective practice.• Take trauma into account.• Avoid triggering trauma reactions or retraumatization.• Recognize the trauma of coercive interventions.• Support the individual’s coping capability.• Allow survivors to manage their trauma symptoms successfully so they can access, retain, and benefit from the services. (Fallot & Harris, 2002; Ford, 2003; Najavits, 2003)
Trauma-Sensitive vs. Trauma- Insensitive Approaches Trauma-sensitive Trauma-insensitive services/approaches services/approaches • Recognition of culture and • “Tradition of toughness” practices that retraumatize valued as best care approach • Power/Control minimized • Keys, security uniforms, staff demeanor, tone of voice • Caregivers/Supporters • Rule Enforcers • Collaboration-focused • Compliance-focused • Staff training builds • “Client-blaming” as fallback awareness, sensitivity position without training • Understand function of • Behavior seen as behavior such as rage, intentionally provocative and repetition-compulsion, self- volitional injury(Fallot & Harris, 2002; Cook et al., 2002; Ford, 2003; Cusack et al., 2004; Jennings, 1998; Prescott, 2000)
Trauma-Sensitive vs. Trauma- Insensitive Workers Trauma-sensitive Trauma-insensitive workers workers • Objective, neutral language • Labeling language: manipulative, needy, gamey, “attention-seeking” • “Let’s talk and find you something • “If I have to tell you one more time to do that will help.” ….” • Focus is on person – eye contact • Focus on task, not person • Says hello and goodbye • Comes and leaves with little acknowledgement(Fallot & Harris, 2002; Cook et al., 2002; Ford, 2003; Cusack et al., 2004; Jennings, 1998; Prescott, 2000)
Client-Centered, Trauma- Informed Approaches • Understanding Triggers • Building Trusting Relationships • Emphasize Strengths • Building Coping Skills • Children and Families
What is a Trigger? • A trigger is a troubling reminder of a traumatic event. • The trigger itself need not be frightening or traumatic. • It can be conscious or unconscious. • Triggers are oftenPhoto: .firstname.lastname@example.org subtle and difficult to anticipate. Adapted from Fagan, Nancy; Kathleen Freme. 2004
Some things that may be triggering• Individual people • Animals• Places • Films or scenes• Emotions within films• Noises • Dates of the year• Images • Tones of voice• Smells • Body positions• Tastes • Bodily sensations• Color • Weather conditions• Environmental • Time factors conditions
Discussion• What are some environmental factors in your agencies or groups that may trigger someone who has experienced trauma?• What may happen when an individual who has experienced trauma is triggered?• What can you do to prevent or minimize crises?
Building Trust • See the family/believe in them • Take the time • Start where they are • See the possibility • Demonstrate compassion • Share hope • Avoid judging • Be responsive to immediate needs • Show respect • Do what you say you will do
HopeEverything we do and say should be infused with the hope and belief that people’s lives change, people get better, and recovery is possible!
Tips for Trauma-Sensitive Relationships • Be aware, mindful, respectful • Don’t probe – let the person raise the issues • Avoid judging or labeling behaviors as manipulation • Maintain strengths-based view • Work through resistance: What is the person trying to tell us?Photo: Aussiegirl@Flikr.com
See the Strengths • As an individual • As a family • As a family member • As a parent • In the environment
Discovering Strengths There are many ways to see strengths of an individual or family, including:• Patterns • Talents – hobbies• Attitudes • Stamina• Coping styles • Common sense• Values – family, cultural, • Relationships social • Interests – desires• Choice • Physical attributes, health• Personality characteristics • Behavior – skills• Environmental – home, • Things person does well community, resources • Achievements• Beliefs • Flexibility• Feelings – emotions • Resourcefulness• Knowledge – intelligence
Sometimes we think ourclients should do onething and they choose todo another.They may have differentpriorities.They may make mistakes.Either way, they are thedecision-makers.
Self DeterminationPeople make choices all the time about treatment programs, but it may look to us like non-compliance! Using self- determination as a principle of case management means to recognize this fact and use it to create “buy-in” for a treatment plan.
Exercise• In pairs – one person is the staff member and one a homeless woman. The homeless woman wants the candy and the staff member wants her to have the carrot.• What happened. What did the case manager do? How did the woman feel? What is the long-term impacts?
Key Questions• Where are you now?• Where do you want to be?• What resources do you have available to help you get there?• What can we do together to help you get where you want to be?
Planning Tips • Remember, it’s not your decision. Help others set goals and prioritize. • Focus on concrete steps • Find and offer practical tools • Don’t be afraid to change horses • Focus on positive action • Coordinate and collaborate
Building Skills• Coping Skills• Responding instead of Reacting• Life Skills• Communication• Parenting (trauma-informed)Always ask – is it practical? Does if fit with the family goals? Make it real! celebrate successes!
Life on Life’s TermsTake it easy!People who are surviving on the streets and in shelters are just that – survivors! You don’t have to meet every need immediately, and they can’t or won’t work on recovery full time.
Worker Reactions Workers may unwittingly repeat client trauma roles: victim, perpetrator, bystander.• Client problems evoke sympathy and vulnerability, which may lead to excessive support and overindulgence rather than encouraging client accountability and growth.• Client struggles can trigger staff frustration, harsh judgments, and punitive confrontations.
The Life Balance Wheel Is your life in balance? Add spokes to the wheel to represent your self‐care activities in each area.
Examples of Trauma Programs• Amaro, H., & Nieves, R. L. (2009). Boston Consortium Model: Trauma-Informed Substance Abuse Treatment for Women. Contact: Hortensia Amaro at email@example.com or Rita Nieves Rita_Nieves@bphc.org.• Clark, C., Fearday, F. (eds) (2003) Triad Women’s Project: Group facilitators manual. Tampa, FL: Louis de la Parte Florida Mental Health Institute, University of South Florida. (contact Colleen Clark at firstname.lastname@example.org)• Covington , S. S. (2003) Beyond Trauma: A Healing Journey for Women. Center City, MN: Hazelton Press. (Contact Stephanie Covington at email@example.com)
Examples of Trauma Programs (continued)• Ford, J.D., Mahoney, K., Russo, E., Kasimer, N., & MacDonald, M. (2003). Trauma Adaptive Recovery Group Education and Therapy (TARGET): Revised Composite 9-Session Leader and Participant Guide. Farmington, CT: University of Connecticut Health Center. (Contact Julian Ford at firstname.lastname@example.org )• Harris, M. (1998). Trauma, Recovery and Empowerment: A Clinician’s Guide for Working with Women in Groups. New York, NY: Free Press. (Contact Rebecca Wolfon Berley at email@example.com)• Miller, D., & Guidry, L. ( 2001). Addictions and Trauma Recovery: Healing the Mind, Body, and Spirit. New York: W.W. Norton. (Contact Dusty Miller at firstname.lastname@example.org)• Najavits, L. (2001). Seeking Safety: Cognitive-Behavioral Therapy for PTSD and Substance Abuse. New York: Guilford. (Go to www.seekingsafety.org)• Saakvitne, K. W., Gamble, S.J., Pearlman, L.A., Lev, B.T. (2000). Risking Connection: A Training Curriculum for Working with Survivors of Childhood Abuse. Maryland: Sidran. (Go to www.sidran.org)
Transformation in the world happens when people are healed and start investing in other people. Michael W. Smith
Thank YouThis presentation has been developed and presentedby Advocates for Human Potential, Inc. with supportby the Substance Abuse and Mental Health Services Administration Deborah Werner, MA – email@example.com Pat Tucker, MA, MBA – firstname.lastname@example.org