Trauma and trauma-informed care


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Powerpoint accompanying workshop session from the Homeless and Housing Coalition of Kentucky's 2013 conference. Presented by Tim Welsh
Trauma is a common occurrence in the lives of homeless individuals and can have a significant impact on one’s
ability to function. This training will help participants identify signs of trauma and ways in which they can engage
in trauma-informed practice with clients

Trauma and trauma-informed care

  1. 1. Trauma and Trauma-Informed Care
  2. 2. About Us…Tim Welsh LCSWMental Health CoordinatorWilliam WoodardPeer Support SpecialistPhoenix Health CenterHealth Care for the Homeless Site
  3. 3.  What is Trauma Impact of Trauma Prevalence Data Core Principles of Trauma-Informed Care Practicing Trauma-Informed Care Challenges/ Effective Methods of Implementation Impact of Trauma Work / Self-Care for the WorkerOverview
  4. 4. The experience of violence and victimizationincluding sexual abuse, physical abuse, severeneglect, loss, domestic violence and/orwitnessing of violence, terrorism, anddisasters.(NASMPHD, 2006)
  5. 5. Trauma . . . Is sudden, unexpected, and perceivedas dangerous or life threatening Overwhelms individual’s ability tomanage daily business as usual
  6. 6. Traumatic Experiences Sexual abuse and/or sexual assault Severe Neglect Physical abuse/violence War Accidents, injury, serious medical illness Deprivation caused by extreme poverty Gang and drug-related violence Imprisonment Oppression Witnessed violence and cruelty to others Emotional and psychological abuse Repeated abandonment or sudden loss
  7. 7. Trauma is Person-Specific•Two people who view/experience the sameevent/trauma may not react in the samemanner.•What is traumatic for one person may not betraumatic for another
  8. 8. The Impact of Trauma
  9. 9. The Impact of Trauma Body & Brain: Neurobiology- fight/flight/freeze response.Survivors often feel the biological responses offight/flight/freeze all the time and can’t act on it, leaving themin constant state of hyperarousal, fear and anxiety Memory & Perception: Often fragmented and difficultyconcentrating Judgment: Insight, perspective, ability to see and weighconsequences, ability to set boundaries. Imagine the effectson one’s judgment if their caregivers had also their abusers.They could have an inability to recognize “red flags”.(Saakvitne, et al., 2000)
  10. 10. The Impact of Trauma Beliefs: What it means to feel safe, trust, have self-esteem, feel connected, and to feel in control in ourlives. Frame of Reference: Identity (Who am I?); World view(What is the world really like?); Spirituality (What do Ibelieve?) Feelings: Ability to identify and manage feelings.Ability to connect to others(Saakvitne, et al., 2000)
  11. 11. Prevalence of TraumaSubstance Abuse Population- United States Up to 2/3’s of men and women in substance abusetreatment report childhood abuse and neglect Study of male veterans in substance abuse inpatientunit found: 77% exposed to severe childhoodtrauma; 58% history of lifetime PTSD 50% of women in substance abuse treatment havehistory of rape or incest(Governor’s Commission on Sexual and Domestic Violence, Commonwealth of MA, 2006; SAMHSA CSAT, 2000;Triffleman et al., 1995)
  12. 12. ACE Adverse Child Experiences Study Recurrent physical abuse Recurrent emotional abuse Contact sexual abuse An alcohol and/or drug abuse in the home An incarcerated household member Someone who is chronically depressed, mentallyill, institutionalized, or suicidal Mother is treated violently One or no parents Emotional or physical neglect (Anda & Felitti, 1998)
  13. 13. ACE Study Findings ACEs have a significant impact on later adult health andwell-being ACEs have a strong influence on the development ofhigh risk behaviors (i.e. smoking, illicit drug use, sexualbehavior) ACEs increase the risk of physical health issues (heartdisease, lung disease, HIV and STDs, obesity)(Anda & Felitti, 1998)
  14. 14. ACE Scores and Behavior ACE Score > 4 Twice as likely to smoke Seven times as likely to have alcohol abuse/dependence Twice as likely to have cancer or heart disease Four times as likely to have emphysema or COPD Twelve times as likely to have attempted suicide(Anda & Felitti, 1998)
  15. 15. ACE Scores and Behavior cont. Men with an ACE score of > 6 were 46 timesmore likely to use IV drugs People with ACE score of > 7Who did NOT smoke, drink to excess or weigh more thanhealthy weight range had a 360% higher risk of ischemicheart disease(Anda & Felitti, 1998)
  16. 16. History of Trauma Among Homeless Adults•Childhood:•27% lived in foster care, group home or otherinstitutional setting.•25% were physically or sexually abused.•21% were homeless.•Adulthood:•23% are veterans.•15.3% of jail inmates have been homeless atsome point and have high rates of othertraumatic experiences:•-31% have been phsycially or sexuallyabused.•-46% have been shot at (excludes militarycombat)•-49% have been attacked with a knife orother sharp object.(Burt et al., 1999; National Coalition for the Homeless, 2007)
  17. 17. History of Trauma Among Homeless AdultsWomen:• 97% of homeless women with SMI haveexperienced severe physical & sexual abuse-87% experience this abuse both in childhoodand adulthood.• 92% of homeless mothers have experiencedsevere physical or sexual assaults over theirlifespan.Men: A 2010 study looked at the prevalence oftrauma for 239 homeless men and found:•68% reported childhood physical abuse•71% reported adulthood physical abuse•56% reported childhood sexual abuse•53% reported adulthood sexual abuse(Bassuk et al., 1996; Kim et al., 2010)
  18. 18. Histories of Trauma Among Youth Family conflict/violence is the primarycause of homelessness. 46% have been physically abused. Foster care involvement: One in five youth who arrived at shelters came directlyfrom foster care. Over 25% had been in foster care in the previous year.(U.S. Department of Health and Human Services, 1997)
  19. 19. Histories of Trauma Among LGBT Youth Comprises 20% to 40% of homeless youth. Coming out is often associated with beingkicked out of home or physically assaulted. Risky sexual behaviors are prevalent(increasing the risk of HIV). Seven times more likely to be a victim of violent crime.(National Gay and Lesbian Task Force Policy Institute and the National Coalition for the Homeless, 2006)
  20. 20. Trauma-Informed Care is…“ Trauma-Informed Care is a strengths-based framework that is grounded in anunderstanding of and responsiveness tothe impact of trauma, that emphasizesphysical, psychological and emotionalsafety for both providers and survivors, andthat creates opportunities for survivors torebuild a sense of control andempowerment.”(Hopper et. al., 2010)
  21. 21. Trauma-Informed Care is…• An understanding of what trauma is and how it effectspeople’s outlook and behavior.• A manner of interacting with clients with the assumptionthat they have experienced trauma. This ensures that allcommunication is less likely to trigger a negative responsein clients while at the same time conveying safety, care andrespect.• Agency wide. From the front office staff, the socialworkers to the janitors.
  22. 22.  We work to establish relationships with people who mayhave been humiliated, hurt or betrayed by those who aresupposed to be counted on for safety and protection.What does all this mean for our work?
  23. 23. Why Trauma-Informed? Misunderstood or ignored signs of trauma may: Interfere with help-seeking Limit engagement into services Lead to early drop out Inadvertently re-traumatize people we are trying to help Lead to failure to make appropriate referrals(Peterson, 2011)
  24. 24. The Core Principles of aTrauma-Informed Culture Safety: Ensuring physical and emotional safety; do no harm Trustworthiness: Maximizing trustworthiness, making tasksclear, maintaining appropriate boundaries Choice: Prioritizing consumer choice & control over recovery Collaboration: Maximizing collaboration & sharing of powerwith consumers Empowerment: Identifying what a person can do forthemselves; prioritizing skill-building that promotes recovery;helping consumer find inner strengths to heal(Adapted from Beyer, L.L., 2010)
  25. 25. Trauma-Informed Care“What has happened to you?”Instead of“What is wrong with you?”
  26. 26. Using a Trauma LensAttitudes and behaviors arethe individual’s best attempt to cope.
  27. 27. Trauma-Informed CareWe need to presume the clients we serve havea history of traumatic stress and exercise“universal precautions” by creating systems ofcare that are trauma-informed. (Hodas, 2005)
  28. 28. Viewing Symptoms as Adaptations A TIC model frames survivors’ symptoms asadaptation, rather than as pathology Every symptom helped a survivor in the past andcontinues to help in the present – in some way Emphasizes resilience in human response to stress Reduces shame Engenders hope for clients and providers alike
  29. 29. Viewing Symptoms as Adaptations Not trusting anyone Hypervigilence Not asking for help Fear of shelters Fear of crowds Not bathing (Shelters with open shower stalls) Not willing to use medical or dental services Not taking medications(Schilling, 2010)
  30. 30. Viewing Symptoms as Adaptations Aggression Not waiting for appointments; staying “on the move” Finding a protector Self-destructive behavior Self-harm Suicidality Exchanging sex for money or necessities Use of drugs and/or alcohol(Schilling, 2010)
  31. 31. Challenges in ImplementingTrauma Informed Care
  32. 32. Challenges in ImplementingTrauma Informed Care• Differing Philosophies• Lack of Time• Ignorance• Old Habits Die Hard• Physical/space limitations
  33. 33. Ways of Ensuring EffectiveImplementation ofTrauma Informed Care•Client input (!)•Mystery Shoppers•Keep your eyes and ears open•Analyze and learn from failures/system breakdowns•Train and Retrain
  34. 34. SafetyThe first stage of healing from trauma:Establish SAFETY(Herman, 1997)
  35. 35. Establishing Physical and Emotional Safety Speak in a calm, respectful voice Provide consumer with personal space Establish a safe place to talk and be alert to signs of discomfort or unease Emphasize consumer ability to stop discussion and model respect forconsumer choices Try to make space as calm and relaxing as possible, including removing anypotential triggers for trauma Validate feelings and honor honesty
  36. 36. Safety• Use “What is safe?” question as a tool foridentifying action steps towards recovery.• Engage consumer in discussion of rating safety ofdifferent options as well as determining specificways to increase level of safety.• The goal of services is to return a sense ofautonomy and control through safer choice-making.(Najavits, 2002)
  37. 37. Creating a Safe Environment• Minimize re-victimization• Avoid such strategies as:• Shaming• Moral inventories in isolation• Confrontation• Intrusive monitoring• Reduce triggering situations.(Schilling, 2010)
  38. 38. Triggering Procedures or Situations• Lack of control/ Powerlessness• Threat or use of physical force• Interacting with authority figures• Loud noises• Lack of information• Intrusive or personal questions• Unfamiliar surroundings• Reminders of the past• Others?(Schilling, 2010)
  39. 39. Creating a Safe EnvironmentWhen an event is likely to be triggering Acknowledge Help the consumer to predict what will happen Give as much choice and control as possible Encourage use of self-regulation strategies during the event Make space for recovery after event Encourage/provide self-soothing during the event(Schilling, 2010)
  40. 40. Establishing Safety &Crisis ManagementAdvance collaborative planning: Help consumer to identify triggers for distress Help consumer to identify ways to safely calm downor self-soothe Provide resources for self-regulation(Schilling, 2010)
  41. 41. Creating a Safety Plan Collaborate with the individual to identify triggers and situations thatmay pose a threat to safety. Assist individual to identify coping skills- safe ones- that he/she hastried before successfully to manage a trigger. Facilitate discussion of additional skills that he/she would be willing toexplore as ways to manage triggers. Identify support people for contact in the case of crisis. Identify what actions are not helpful in the time of crisis. Emphasize emergency crisis plan with emergency phone numbers andidentification of hospital if needed.
  42. 42. EstablishingSafety & Crisis ManagementAssist agitated consumers in a non-aggressive & non-threatening manner Stay calm Make eye contact Keep appropriate physical distance Be respectful and non-judgmental Offer options Focus on de-escalation not winning vs. losing(Schilling, 2010)
  43. 43. What Helps with Upset Consumers Be calm Listen, validate, allow to ventilate Determine whether there is an actual emergency If there is- deal with that Offer options Give clear information and suggestions If no emergency, what does the consumer want to addressright now? Help consumer to focus on realistic plan of action(Schilling, 2010)
  44. 44. Helpful Coping Skills Grounding Self-soothing Making safer choices Information(Schilling, 2010)
  45. 45. Trauma and RelationshipRecognize that since trauma mostoften occurs in relationship, healing andrecovery must also occur in relationship.(Schilling, 2010)
  46. 46. Trauma and RelationshipSince trauma occurred in relationship,healing occurs by changing the elements of relationship•From abusive to nurturing•From unresponsive to empathic•From lies and denial to authenticity and honesty•From controlling to empowering(Schilling, 2010)
  47. 47. The Role of Power in theProvider Relationship In traditional case management paradigms, power and controlare held by the staff. The term case management hasimplications that contradict core principles of TIC. In TIC service systems, power and control are held by theconsumer: Collaboration and cooperation are central concepts Staff and consumer collaborate on service plans, housingarrangements, financial decisions and medication orders Staff empower the consumer’s voice rather than silencing it(Harris & Fallot, 2001)
  48. 48. Collaboration Follow the consumer’s lead on current goals, needs and wants. Present options for services and respect the consumer’s choices. Assist the consumer to learn self-advocacy and promote involvement inservices as well as sharing concerns regarding services. Involve consumers in planning of services. Use Motivational Interviewing techniques.
  49. 49. Strengths-Based Approach Highlighting the assets of the consumer in the assessment andintervention helps empower the consumer to connect withresilience and hope. Focus on positive steps towards change and notice periods ofsuccess and factors that contributed to success.
  50. 50. Self-Care & Wellnessfor the Clinician
  51. 51. The Challenges of Working With ThoseAffected by Trauma Burnout Compassion Fatigue Vicarious Trauma
  52. 52. Impact of Trauma Work Can alter the clinician’s view of the world and other people.May lead to pessimism and cynicism. Decreased feelings of safety. Increased paranoia orquestioning of others’ intentions. Clinician may become overly concerned with safety of self andconsumers or may become numb to sense of danger and misssigns of risky behavior for self or consumers. Can affect clinician’s connection to others and relationshipwith spiritual beliefs. Decreased sense of hope. Physical and emotional exhaustion.(Harris & Fallot, 2001)
  53. 53. Risks for IncreasedTrauma Work Impact Working solely with consumers affected by trauma Working in an agency that does not support trauma-informed care Lack of understanding about trauma dynamics and typicaltrauma-related behaviors Clinician history of trauma May overextend self to help survivors May expect others to follow same recovery steps May not be aware of own trauma history and unconsciouslydeny or avoid exploring trauma
  54. 54. Possible Work Factors that Increase the Impact ofTrauma Work Work with consumers where concrete signs of success may befew Consumers with few resources and multiple problems Exposure to complex consumer situations Consumers who are difficult to engage Lack of community and organizational resources Not enough recovery time between client meetings Lack of recognition of the impact of trauma work asoccupation risk of the type of work being done Poor recognition of the value of the work being done Time pressures and paper workload Exposure to possible unsafe work situations(Rose, 2007)
  55. 55. Possible Individual Factors that Increase theImpact of Trauma Work Personal history Personality Current personal circumstances Level of professional development High ideals/ rescue fantasies/ over-investment in meetingall of client’s needs. Those most vulnerable to ITW mayview themselves as saviors or rescuers Working without supervision and/or consultation Poor support network Personal style of coping(Figley, 1995; Rose, 2007)
  56. 56. Individual Ways to Reduce the ITW Psychological: Sustain balance between work and play Effective relaxation time and methods Using meditation or spiritual practice that iscalming Self assessment and self awareness Frequent contact with nature or other calming stimuli Methods for creative expression(Rose, 2007)
  57. 57. Individual Ways to Reduce the ITW Physical: Body work: Monitoring parts of your body for tension andusing methods to release tension Healthy sleep schedule Healthy nutrition(Rose, 2007)
  58. 58. Individual Ways to Reduce the ITW Social/Interpersonal: Social supports: At least 5 people, including 2 at work, whowill be highly supportive when called on Getting help: Knowing when and how to access help, bothinformal and formal Social activism: Being involved in social justice activities toaddress injustice(Rose, 2007)
  59. 59. Inventory of Self-Care Balance between work and home Boundaries/limit setting Time boundaries/ monitor overworking Personal boundaries Professional boundaries Dealing with multiple roles Realistic sense of things you can change and acceptingthose you can not(Rose, 2007)
  60. 60. Inventory of Self-Care Getting help and support at work Peer support Supervision Consultation Role models/ mentors Increasing work satisfaction: Remember the joys and achievements Count the small steps towards success(Rose, 2007)
  61. 61. Wisdom for the JourneyHope is not believing that we can change things.Hope is believing that what we do makes a difference.Vaclav Havel
  62. 62. Tim Welsh LCSWtwelsh@fhclouisville.org502 569 1662
  63. 63. Trauma Screening“Trauma screening refers to abrief, focused inquiry to determinewhether an individual has experiencedspecific traumatic events.”(Harris & Fallot, 2001)
  64. 64. Trauma ScreeningTwo primary factors contribute to trauma concernsbeing overlooked: Under-reporting of trauma by survivors Under-recognition of trauma by providers(Harris & Fallot, 2001)
  65. 65. Under Reporting of Trauma Immediate safety concerns (i.e. fear of retaliation fromabusers) May fear stigma or responses that disbelieve or blamethe victim or pathologize attempts to cope with trauma Some feel ashamed about being victimized and theattached sense of weakness Some, especially men, withdraw and isolate Childhood experiences may not be clearly remembered(Harris & Fallot, 2001)
  66. 66. Under Recognition of Trauma Providers may feel uncomfortable asking abouttrauma, fearing that they will not be able to manage theresponse Providers may not want to ask because of lack of services toaddress trauma concerns Providers may use vague or unclear terms that do notcorrespond to consumer’s experience of past trauma (i.e.violent physical abuse may be understood to have been“discipline”)(Harris & Fallot, 2001)
  67. 67. Reasons for Trauma Screening A main purpose is to identify effective follow-up andreferral, including determining need for immediate response ifrisk of imminent danger exist. Screening demonstrates that agency identifies violence andabuse as important events in the consumer’s life and that staffare comfortable discussing trauma with consumers. Even if consumer declines to report, staff have initiated theconversation and increased likelihood that consumer mayrevisit trauma concerns later.(Harris & Fallot, 2001)
  68. 68. Basics of Trauma Screening Adequate consumer and clinical preparation Establish safety Look at individual needs and contextual issues Follow consumer cues on whether to proceed Explain rationale for questions Ask permission to ask and give permission to pass/end Limit screening to several questions Preparation for limited disclosure initially Be clear and straightforward Consider self-administered questionnaire(Harris & Fallot, 2001)
  69. 69. Basics of Trauma Screening Complete screening with discussion of implications forresources. Express appreciation for consumer participation and/orconsumer ability to self-protect by passing on questions orending discussion. Provide education and information regarding impact of traumaas well as emphasize ability to heal from trauma as well asresilience.(Harris & Fallot, 2001)
  70. 70. Adverse Child Experiences Study(ACE