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TRAUMA-INFORMED CARE   Nancy J. Smyth, PhD, LCSW       Professor & Dean    UB School of Social Work NYS School Social Work...
Much of this content is from online workshop developedby Professor Sue Green & myself on trauma-informedcare and creating ...
Agenda• Mental Health System: Why This is  Needed: Case Example• Trauma: Definition & Impact• Trauma-Informed Care
http://www.theannainstitute.org/obi.htmlANNA CAROLINE JENNINGS1960 - 1992
This is Anna at age one      This is Anna years       and a half            later – in a mental                           ...
Annas Retraumatization In Mental         Health System     Jennings, A. (1994) On being invisible in the     mental health...
Trauma Definitions• DSM IV: Event involving actual or  threatened death or serious injury, or a  threat to physical integr...
Defining TraumaMcCann and Pearlman (1990)Psychological trauma:• is sudden, unexpected, or non-normative.• Exceeds the indi...
Consequences of TraumaIncreased: – Fight, flight, freeze response – Hypervigilance, arousal, paranoia – Perceptual and inf...
Consequences of TraumaDecreased: – Memory processing and retrieval – Reality testing – Body and emotional awareness – Immu...
Trauma Reactions• Type I: Short-term, unexpected event  – Examples: One time rape, car accident, natural    disaster  – Li...
Prevalence of Trauma• Study of 2nd yr. students in college found that at  least 84% had experienced at least one major  tr...
Prevalence of TraumaAt Risk Populations• Mental Health Tx: 40%-60% childhood  victimization• Substance Abuse Tx:  –   60%-...
Youth Rates• National Study of 12-17 yr. olds (Kirkpatrick &  Saunders):   – 8% sexual assault   – 17% physical assault   ...
Impact on CognitionsPeople will hurt meI’m helpless to prevent bad things fromhappeningI’m defectiveI don’t matterI’m help...
Adverse Childhood Experiences          (ACE) Study• Collaboration between Kaiser Permanente of San Diego and  Centers for ...
Adverse Childhood Experiences          (ACE) Study• Middle class adults (N = 17,337) 54% female, 46% male.• Race/Ethnicity...
Adverse Childhood                Experiences (ACEs)Growing up experiencing any of the following conditions     in their ho...
ACEs increase the adult risk      for many health problems            (Felitti et al., 1998)• Heart disease              •...
ACEs increase the riskfor many other social problems       (From www.cdc.gov/ace) •  Intimate partner violence •  Multiple...
Adverse Childhood Experiences          (ACE) Study• ACEs very common:   – 2/3 of the sample had 1+   – > 1 in 10 had 5 +• ...
The Impact of Trauma on the           Brain
Information Processing & The            BrainLeft Hemisphere          Right Hemisphere• Language               • Evaluates...
Traumatic Memory           Fragmentation• The Compartmentalization of Experience:  elements of a trauma are not integrated...
Normal vs. Traumatic Memory Event         Event              B A BASK             K               S
“THE WALL”
“THE WALL”             (Greenwald, 2005)The “Trauma Wall”  – Sometimes upsetting experiences do not get    processed; some...
“THE WALL”• Problems with “The Wall”  – Memory stays fresh, keeps its power  – Conflict between cognition and emotion: the...
Emotional Hijacking        (Goleman; Nijenhuis)                         Emotional “Pocket”Apparently Normal         (Holds...
Systems of CareMessages/Actions confirming traumogenicperceptions of self & others:     No progress expected           “yo...
What is “Retraumatization”? A situation, attitude, interaction, or environment  that replicates the events or dynamics of...
Impacts of Retraumatization on             Consumers Decrease or loss of trust Higher rates of self-injury Significantl...
Trauma-Informed CareWill avoid inadvertent retraumatization andwill facilitate consumer participation intreatment         ...
Trauma-Informed Care (TIC)We stop asking:  “What is wrong with this person?”and begin asking….   “What has happened to thi...
Trauma-Informed CareMay not be specifically designed to treat the actual  trauma, but:   – Are informed about   – Sensitiv...
Trauma-Informed Care Provides services which allow clients to• feel safe• be accepted• be understood  by everyone who may ...
5 Guiding Principles of TIC                    1. Safety                                        2.    5.                  ...
5 Guiding Principles of TIC                           1. Safety                    includes where services are offered; ti...
5 Guiding Principles of TIC                              1. Safety        includes providing clear information about what ...
5 Guiding Principles of TIC                         1. Safety                                                    2.    5. ...
5 Guiding Principles of TIC                          1. Safety                                                       2.   ...
5 Guiding Principles of TIC                         1. Safety                                                      2.     ...
Culture Change in Human              Service Programs1. Initial Planning2. A kickoff Training Event3. Short-term follow-up...
Culture Change in Human             Service ProgramsService-Level Changes:• Program Procedure and Settings• Formal Service...
Culture Change in Human             Service ProgramsSystems-level/Administrative Changes• Program-Wide Trauma Informed Ser...
TIC in Schools• What Practices/Processes Are Likely  Triggers?• What Would TIC look like in a School?
Although the world is very full of   suffering, it is also full of the         overcoming of it.                      – He...
Resources• Podcasts (free audio recordings) on UBSSW website:  http://www.socialwork.buffalo.edu/podcast/ and sort on  cat...
Guiding Principles of Trauma-Informed Care                                                                    (Fallot & Ha...
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Trauma-Informed Care, November 2011

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Workshop presented by Nancy J. Smyth, PhD, LCSW at NYS School Social Workers Association Annual Conference, Buffalo, NY 11/4/11

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Transcript of "Trauma-Informed Care, November 2011"

  1. 1. TRAUMA-INFORMED CARE Nancy J. Smyth, PhD, LCSW Professor & Dean UB School of Social Work NYS School Social Workers Association Annual Conference Buffalo, NY 11/4/11
  2. 2. Much of this content is from online workshop developedby Professor Sue Green & myself on trauma-informedcare and creating trauma-informed organizations.
  3. 3. Agenda• Mental Health System: Why This is Needed: Case Example• Trauma: Definition & Impact• Trauma-Informed Care
  4. 4. http://www.theannainstitute.org/obi.htmlANNA CAROLINE JENNINGS1960 - 1992
  5. 5. This is Anna at age one This is Anna years and a half later – in a mental institution What happened?
  6. 6. Annas Retraumatization In Mental Health System Jennings, A. (1994) On being invisible in the mental health system. Journal of Behavioral Health Services , 21(4), 374-387. See http://www.theannainstitute.org/obi.html
  7. 7. Trauma Definitions• DSM IV: Event involving actual or threatened death or serious injury, or a threat to physical integrity of self/others (experienced/witnessed) (DSM-IV)• Meichenbaum (1994): Event(s) so extreme, severe, powerful, harmful, or threatening they require extraordinary coping efforts (experienced /witnessed)
  8. 8. Defining TraumaMcCann and Pearlman (1990)Psychological trauma:• is sudden, unexpected, or non-normative.• Exceeds the individual’s perceived ability to meet its demands• Disrupts the individual’s frame of reference and... psychological needs...
  9. 9. Consequences of TraumaIncreased: – Fight, flight, freeze response – Hypervigilance, arousal, paranoia – Perceptual and information processing distortions – Pain tolerance – Emotional blunting – Aggression and irritability
  10. 10. Consequences of TraumaDecreased: – Memory processing and retrieval – Reality testing – Body and emotional awareness – Immune response
  11. 11. Trauma Reactions• Type I: Short-term, unexpected event – Examples: One time rape, car accident, natural disaster – Likely to result in typical PTSD sx• Type II: (Complex Trauma): Sustained, repeated ordeal stressors – Examples: ongoing physical/sexual abuse, combat – More likely to result in long-standing characterological & interpersonal problems, dissociation, substance abuse
  12. 12. Prevalence of Trauma• Study of 2nd yr. students in college found that at least 84% had experienced at least one major trauma (Vrana & Lauterbach,1994)• “Some people never experience the most serious levels of trauma in their lifetimes, however, the majority of people experience at least one traumatic stressor….” (Resick, 2001)
  13. 13. Prevalence of TraumaAt Risk Populations• Mental Health Tx: 40%-60% childhood victimization• Substance Abuse Tx: – 60%-70% women child victimization – 90% women domestic violence – 60% men physical assault victims – 33% men child sexual abuse
  14. 14. Youth Rates• National Study of 12-17 yr. olds (Kirkpatrick & Saunders): – 8% sexual assault – 17% physical assault – 39% witnessing violence• Western North Carolina Study (Copeland et al., 2007). Instead of full blown PTSD, children experienced school problems, emotional difficulties, and physical problems – 20% of children exposed to 1 trauma – 50% of children exposed to >1
  15. 15. Impact on CognitionsPeople will hurt meI’m helpless to prevent bad things fromhappeningI’m defectiveI don’t matterI’m helplessI’m worthlessI can’t trust anyoneYou will hurt me
  16. 16. Adverse Childhood Experiences (ACE) Study• Collaboration between Kaiser Permanente of San Diego and Centers for Disease Control and Prevention (CDC).• Initial phase conducted from 1995-1997 in two waves.• Participants were given a standardized physical exam and completed a confidential survey on child maltreatment, family dysfunction, current health status and behaviors.• Unique opportunity to examine the relationships between a broad range of adverse childhood experiences (ACEs) and a wide range of health and social consequences in adulthood. (Adapted from http://www.cdc.gov/ace/prevalence.htm)
  17. 17. Adverse Childhood Experiences (ACE) Study• Middle class adults (N = 17,337) 54% female, 46% male.• Race/Ethnicity: 75% White; 11% Hispanic/Latino; 7% Asian/Pacific Islander; 5% African-American; 2% other.• Age (years): 5% 19-29; 10% 30-39; 19% 40-49; 20% 50-59; 46% 60 and over (mean age = 56).• Education: 39% college graduate or higher; 36% some college; 18% high school graduate; 7% did not graduate from high school. (Adapted from http://www.cdc.gov/ace/prevalence.htm)
  18. 18. Adverse Childhood Experiences (ACEs)Growing up experiencing any of the following conditions in their household prior to age 18: 1. Recurrent physical abuse 2. Recurrent emotional abuse 3. Contact sexual abuse 4. An alcohol and/or drug abuser in the household 5. An incarcerated household member 6. Someone in the household who is chronically depressed, mentally ill, institutionalized, or suicidal 7. Mother is treated violently 8. Parents separated or divorced 9. Emotional neglect 10. Physical neglect
  19. 19. ACEs increase the adult risk for many health problems (Felitti et al., 1998)• Heart disease • Diabetes• Chronic lung • Stroke disease • Skeletal fractures• Liver disease • Poor self-rated health• Cancer • Other risks for the• Physical inactivity leading causes of and obesity death
  20. 20. ACEs increase the riskfor many other social problems (From www.cdc.gov/ace) • Intimate partner violence • Multiple sexual partners • Unintended pregnancies • Early initiation of sexual activity • Adolescent pregnancy • Sexually transmitted diseases (STDs) • Fetal death
  21. 21. Adverse Childhood Experiences (ACE) Study• ACEs very common: – 2/3 of the sample had 1+ – > 1 in 10 had 5 +• ACEs are highly interrelated: tend to occur in clusters rather than as single experiences; the occurrence of one should prompt a search for others.• Interrelatedness suggests examining tthe effects of a single ACE on health and well-being is misguided.• Cumulative impact of multiple exposures can be captured in an “ACE Score.”• Consequently, an integrated approach is needed to intervene early with children growing up in households where ACEs are present. (Adapted from Anda, 2007)
  22. 22. The Impact of Trauma on the Brain
  23. 23. Information Processing & The BrainLeft Hemisphere Right Hemisphere• Language • Evaluates emotional Production sense data• Stores Narrative • Integrates Sense Data Data• Cognitive Analysis • Non-• Declarative/Explicit declarative/Implicit
  24. 24. Traumatic Memory Fragmentation• The Compartmentalization of Experience: elements of a trauma are not integrated into a whole narrative or sense of self.• BASK Model of Memory (Braun) – Behavior: What we do – Affect: What we feel – Sensation: What we perceive in our bodies – Knowledge: What we think and remember
  25. 25. Normal vs. Traumatic Memory Event Event B A BASK K S
  26. 26. “THE WALL”
  27. 27. “THE WALL” (Greenwald, 2005)The “Trauma Wall” – Sometimes upsetting experiences do not get processed; sometimes its just too much to face – Maybe the event was too upsetting and overwhelming – Many people try to push the unsettling experience ‘behind the wall’: it is a representation of a temporary solution
  28. 28. “THE WALL”• Problems with “The Wall” – Memory stays fresh, keeps its power – Conflict between cognition and emotion: the head and the heart – Memories leak out: memory is triggered or activated by something thematically related – Memories stockpiled behind the wall become a ‘sore spot’ (Greenwald,2005)
  29. 29. Emotional Hijacking (Goleman; Nijenhuis) Emotional “Pocket”Apparently Normal (Holds Traumatic Self Memory) Consciousness
  30. 30. Systems of CareMessages/Actions confirming traumogenicperceptions of self & others: No progress expected “you’re defective and hopeless” Disregarding valid needs/requests “you don’t matter” Over-emphasis on Compliance vs. Collaboration “you are powerless”
  31. 31. What is “Retraumatization”? A situation, attitude, interaction, or environment that replicates the events or dynamics of the original trauma and triggers the overwhelming feelings and reactions associated with them Can be obvious - or not so obvious Is usually unintentional Is always hurtful - exacerbating the very symptoms that brought the person into services
  32. 32. Impacts of Retraumatization on Consumers Decrease or loss of trust Higher rates of self-injury Significantly less willingness to engage in any treatment Increase of intrusive memories, nightmares and flashbacks Reexperiencing of symptoms and emotions from previous trauma – when extreme may take on delusional intensity Increase in chronicity of stress with greater risk for psychiatric morbidity, e.g. PTSD, chronic depression
  33. 33. Trauma-Informed CareWill avoid inadvertent retraumatization andwill facilitate consumer participation intreatment (Harris & Fallot, 2001)
  34. 34. Trauma-Informed Care (TIC)We stop asking: “What is wrong with this person?”and begin asking…. “What has happened to this person?”
  35. 35. Trauma-Informed CareMay not be specifically designed to treat the actual trauma, but: – Are informed about – Sensitive to trauma related issues present in survivors and communities – May treat with trauma-specific treatments (Jennings, 2004)
  36. 36. Trauma-Informed Care Provides services which allow clients to• feel safe• be accepted• be understood by everyone who may come in contact with the client
  37. 37. 5 Guiding Principles of TIC 1. Safety 2. 5. TrustworthinessEmpowerment 4. Collaboration 3. Choice
  38. 38. 5 Guiding Principles of TIC 1. Safety includes where services are offered; time of day that services are offered; security personnel available, open doors or locked and the affect that each has on 2. 5. consumers; waiting room appearance; are all staff TrustworthinessEmpowerment members attentive to signs of consumer discomfort and do they recognize these signs in a trauma informed way? (Fallot and Harris, 2006) 4. Collaboration 3. Choice
  39. 39. 5 Guiding Principles of TIC 1. Safety includes providing clear information about what will be done, 2. 5. by whom, when, why and under what circumstances; TrustworthinessEmpowerment respectful and professional boundaries; is unnecessary consumer disappointment avoided; is informed consent taken seriously on a consistent basis? (Fallot and Harris, 2006) 4. Collaboration 3. Choice
  40. 40. 5 Guiding Principles of TIC 1. Safety 2. 5. includes how much choice consumers TrustworthinessEmpowerment have over the services they receive (such as time of day, gender preferences for service providers, etc.); are consumers provided a clear and appropriate message about their rights and responsibilities? 4. Collaboration 3. Choice (Fallot and Harris, 2006)
  41. 41. 5 Guiding Principles of TIC 1. Safety 2. 5. TrustworthinessEmpowerment consumers a significant role in planning includes giving and evaluating services; consumer preference is given in areas of service planning, goal setting, and developing treatment priorities; cultivating an atmosphere of doing “with” rather than doing “to” or “for”; conveying the message that the consumer is the expert in their own life? (Fallot and Harris, 2006) 4. Collaboration 3. Choice
  42. 42. 5 Guiding Principles of TIC 1. Safety 2. 5. TrustworthinessEmpowerment includes recognizing consumer strengths and skills; building a realistic sense of hope for the client’s future; provide an atmosphere that allows consumers to feel validated and affirmed with each and every contact at the agency 4. Collaboration 3. Choice
  43. 43. Culture Change in Human Service Programs1. Initial Planning2. A kickoff Training Event3. Short-term follow-up4. Longer-term follow up(Creating Cultures of Trauma-Informed Care (CCTIC): A Self-Assessment and Planning Protocol, 2009)
  44. 44. Culture Change in Human Service ProgramsService-Level Changes:• Program Procedure and Settings• Formal Service Policies• Trauma Screening, Assessment, Service Planning(Creating Cultures of Trauma-Informed Care (CCTIC): A Self-Assessment and Planning Protocol, 2009)
  45. 45. Culture Change in Human Service ProgramsSystems-level/Administrative Changes• Program-Wide Trauma Informed Services• Staff Trauma Training and Education• Human Resources Practices(Creating Cultures of Trauma-Informed Care (CCTIC): A Self-Assessment and Planning Protocol, 2009)
  46. 46. TIC in Schools• What Practices/Processes Are Likely Triggers?• What Would TIC look like in a School?
  47. 47. Although the world is very full of suffering, it is also full of the overcoming of it. – Helen Keller
  48. 48. Resources• Podcasts (free audio recordings) on UBSSW website: http://www.socialwork.buffalo.edu/podcast/ and sort on categories, then trauma• National Child Traumatic Stress Network: http://www.nctsn.org/• National Center for Trauma-Informed Care; http://www.samhsa.gov/nctic/• UBSSW Continuing Education: http://www.socialwork.buffalo.edu/conted/
  49. 49. Guiding Principles of Trauma-Informed Care (Fallot & Harris)SAFETY: includes where services are offered; time of day that services are offered; security personnel available, open doors or locked and theaffect that each has on consumers; waiting room appearance; are all staff members attentive to signs of consumer discomfort and do theyrecognize these signs in a traumaTRUSTWORTHINESS: includes providing clear information about what will be done, by whom, when, why and under what circumstances;respectful and professional boundaries; is unnecessary consumer disappointment avoided; is informed consent taken seriously on a consistentbasis?CHOICE: includes how much choice consumers have over the services they receive (such as time of day, gender preferences for serviceproviders, etc.); are consumers provided a clear and appropriate message about their rights and responsibilities?COLLABORATION: includes giving consumers a significant role in planning and evaluating services; consumer preference is given in areas ofservice planning, goal setting, and developing treatment priorities; cultivating an atmosphere of doing “with” rather than doing “to” or “for”;conveying the message that the consumer is the expert in their own lifeEMPOWERMENT: includes recognizing consumer strengths and skills; building a realistic sense of hope for the client’s future; provide anatmosphere that allows consumers to feel validated and affirmed with each and every contact at the agency Nancy J. Smyth, PhD, LCSW, University at Buffalo School of Social Work at NYS School Social Workers Association Annual Conference, Buffalo, NY 11/4/11
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