This document provides an overview of trauma and trauma-informed care. It defines trauma as experiences that overwhelm an individual's ability to cope, such as abuse, violence, loss or disasters. Trauma has widespread impacts on physical, emotional and cognitive functioning. High rates of trauma are seen in populations experiencing homelessness, addiction and mental illness. The core principles of trauma-informed care emphasize safety, trust, choice and empowerment. Trauma-informed practices view behaviors as adaptations to past trauma and focus on building safety and resilience. Implementing trauma-informed care requires organizational changes and self-care to prevent burnout among providers from secondary traumatic stress.

1. Trauma and Trauma-Informed Care

2. About Us…
Tim Welsh LCSW
Mental Health Coordinator
William Woodard
Peer Support Specialist
Phoenix Health Center
Health Care for the Homeless Site

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 Worker
Overview

4. The experience of violence and victimization
including sexual abuse, physical abuse, severe
neglect, loss, domestic violence and/or
witnessing of violence, terrorism, and
disasters.
(NASMPHD, 2006)

5. Trauma . . .
 Is sudden, unexpected, and perceived
as dangerous or life threatening
 Overwhelms individual’s ability to
manage daily business as usual

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. Trauma is Person-Specific
•Two people who view/experience the same
event/trauma may not react in the same
manner.
•What is traumatic for one person may not be
traumatic for another

8. The Impact of Trauma

9. The Impact of Trauma
 Body & Brain: Neurobiology- fight/flight/freeze response.
Survivors often feel the biological responses of
fight/flight/freeze all the time and can’t act on it, leaving them
in constant state of hyperarousal, fear and anxiety
 Memory & Perception: Often fragmented and difficulty
concentrating
 Judgment: Insight, perspective, ability to see and weigh
consequences, ability to set boundaries. Imagine the effects
on one’s judgment if their caregivers had also their abusers.
They could have an inability to recognize “red flags”.
(Saakvitne, et al., 2000)

10. The Impact of Trauma
 Beliefs: What it means to feel safe, trust, have self-
esteem, feel connected, and to feel in control in our
lives.
 Frame of Reference: Identity (Who am I?); World view
(What is the world really like?); Spirituality (What do I
believe?)
 Feelings: Ability to identify and manage feelings.
Ability to connect to others
(Saakvitne, et al., 2000)

12. Prevalence of Trauma
Substance Abuse Population- United States
 Up to 2/3’s of men and women in substance abuse
treatment report childhood abuse and neglect
 Study of male veterans in substance abuse inpatient
unit found: 77% exposed to severe childhood
trauma; 58% history of lifetime PTSD
 50% of women in substance abuse treatment have
history of rape or incest
(Governor’s Commission on Sexual and Domestic Violence, Commonwealth of MA, 2006; SAMHSA CSAT, 2000;
Triffleman et al., 1995)

13. ACE Adverse Child Experiences Study
http://www.acestudy.org
 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, mentally
ill, institutionalized, or suicidal
 Mother is treated violently
 One or no parents
 Emotional or physical neglect (Anda & Felitti, 1998)

14. ACE Study Findings
 ACEs have a significant impact on later adult health and
well-being
 ACEs have a strong influence on the development of
high risk behaviors (i.e. smoking, illicit drug use, sexual
behavior)
 ACEs increase the risk of physical health issues (heart
disease, lung disease, HIV and STDs, obesity)
(Anda & Felitti, 1998)

15. 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)

16. ACE Scores and Behavior cont.
 Men with an ACE score of > 6 were 46 times
more likely to use IV drugs
 People with ACE score of > 7
Who did NOT smoke, drink to excess or weigh more than
healthy weight range had a 360% higher risk of ischemic
heart disease
(Anda & Felitti, 1998)

17. History of Trauma Among Homeless Adults
•Childhood:
•27% lived in foster care, group home or other
institutional setting.
•25% were physically or sexually abused.
•21% were homeless.
•Adulthood:
•23% are veterans.
•15.3% of jail inmates have been homeless at
some point and have high rates of other
traumatic experiences:
•-31% have been phsycially or sexually
abused.
•-46% have been shot at (excludes military
combat)
•-49% have been attacked with a knife or
other sharp object.
(Burt et al., 1999; National Coalition for the Homeless, 2007)

18. History of Trauma Among Homeless Adults
Women:
• 97% of homeless women with SMI have
experienced severe physical & sexual abuse-
87% experience this abuse both in childhood
and adulthood.
• 92% of homeless mothers have experienced
severe physical or sexual assaults over their
lifespan.
Men: A 2010 study looked at the prevalence of
trauma 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)

19. Histories of Trauma Among Youth
 Family conflict/violence is the primary
cause of homelessness.
 46% have been physically abused.
 Foster care involvement:
 One in five youth who arrived at shelters came directly
from foster care.
 Over 25% had been in foster care in the previous year.
(U.S. Department of Health and Human Services, 1997)

20. Histories of Trauma Among LGBT Youth
 Comprises 20% to 40% of homeless youth.
 Coming out is often associated with being
kicked 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)

22. Trauma-Informed Care is…
“ Trauma-Informed Care is a strengths-
based framework that is grounded in an
understanding of and responsiveness to
the impact of trauma, that emphasizes
physical, psychological and emotional
safety for both providers and survivors, and
that creates opportunities for survivors to
rebuild a sense of control and
empowerment.”
(Hopper et. al., 2010)

23. Trauma-Informed Care is…
• An understanding of what trauma is and how it effects
people’s outlook and behavior.
• A manner of interacting with clients with the assumption
that they have experienced trauma. This ensures that all
communication is less likely to trigger a negative response
in clients while at the same time conveying safety, care and
respect.
• Agency wide. From the front office staff, the social
workers to the janitors.

24.  We work to establish relationships with people who may
have been humiliated, hurt or betrayed by those who are
supposed to be counted on for safety and protection.
What does all this mean for our work?

25. 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)

26. The Core Principles of a
Trauma-Informed Culture
 Safety: Ensuring physical and emotional safety; do no harm
 Trustworthiness: Maximizing trustworthiness, making tasks
clear, maintaining appropriate boundaries
 Choice: Prioritizing consumer choice & control over recovery
 Collaboration: Maximizing collaboration & sharing of power
with consumers
 Empowerment: Identifying what a person can do for
themselves; prioritizing skill-building that promotes recovery;
helping consumer find inner strengths to heal
(Adapted from Beyer, L.L., 2010)

27. Trauma-Informed Care
“What has happened to you?”
Instead of
“What is wrong with you?”

28. Using a Trauma Lens
Attitudes and behaviors are
the individual’s best attempt to cope.

29. Trauma-Informed Care
We need to presume the clients we serve have
a history of traumatic stress and exercise
“universal precautions” by creating systems of
care that are trauma-informed. (Hodas, 2005)

30. Viewing Symptoms as Adaptations
 A TIC model frames survivors’ symptoms as
adaptation, rather than as pathology
 Every symptom helped a survivor in the past and
continues to help in the present – in some way
 Emphasizes resilience in human response to stress
 Reduces shame
 Engenders hope for clients and providers alike

31. 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)

32. 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)

33. Challenges in Implementing
Trauma Informed Care

34. Challenges in Implementing
Trauma Informed Care
• Differing Philosophies
• Lack of Time
• Ignorance
• Old Habits Die Hard
• Physical/space limitations

35. Ways of Ensuring Effective
Implementation of
Trauma Informed Care
•Client input (!)
•Mystery Shoppers
•Keep your eyes and ears open
•Analyze and learn from failures/system breakdowns
•Train and Retrain

36. Safety
The first stage of healing from trauma:
Establish SAFETY
(Herman, 1997)

37. 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 for
consumer choices
 Try to make space as calm and relaxing as possible, including removing any
potential triggers for trauma
 Validate feelings and honor honesty

38. Safety
• Use “What is safe?” question as a tool for
identifying action steps towards recovery.
• Engage consumer in discussion of rating safety of
different options as well as determining specific
ways to increase level of safety.
• The goal of services is to return a sense of
autonomy and control through safer choice-making.
(Najavits, 2002)

39. Creating a Safe Environment
• Minimize re-victimization
• Avoid such strategies as:
• Shaming
• Moral inventories in isolation
• Confrontation
• Intrusive monitoring
• Reduce triggering situations.
(Schilling, 2010)

40. 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)

41. Creating a Safe Environment
When 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)

42. Establishing Safety &
Crisis Management
Advance collaborative planning:
 Help consumer to identify triggers for distress
 Help consumer to identify ways to safely calm down
or self-soothe
 Provide resources for self-regulation
(Schilling, 2010)

43. Creating a Safety Plan
 Collaborate with the individual to identify triggers and situations that
may pose a threat to safety.
 Assist individual to identify coping skills- safe ones- that he/she has
tried before successfully to manage a trigger.
 Facilitate discussion of additional skills that he/she would be willing to
explore 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 and
identification of hospital if needed.

44. Establishing
Safety & Crisis Management
Assist 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)

45. 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 address
right now?
 Help consumer to focus on realistic plan of action
(Schilling, 2010)

46. Helpful Coping Skills
 Grounding
 Self-soothing
 Making safer choices
 Information
(Schilling, 2010)

47. Trauma and Relationship
Recognize that since trauma most
often occurs in relationship, healing and
recovery must also occur in relationship.
(Schilling, 2010)

48. Trauma and Relationship
Since 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)

49. The Role of Power in the
Provider Relationship
 In traditional case management paradigms, power and control
are held by the staff. The term case management has
implications that contradict core principles of TIC.
 In TIC service systems, power and control are held by the
consumer:
 Collaboration and cooperation are central concepts
 Staff and consumer collaborate on service plans, housing
arrangements, financial decisions and medication orders
 Staff empower the consumer’s voice rather than silencing it
(Harris & Fallot, 2001)

50. 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 in
services as well as sharing concerns regarding services.
 Involve consumers in planning of services.
 Use Motivational Interviewing techniques.

51. Strengths-Based Approach
 Highlighting the assets of the consumer in the assessment and
intervention helps empower the consumer to connect with
resilience and hope.
 Focus on positive steps towards change and notice periods of
success and factors that contributed to success.

52. Self-Care & Wellness
for the Clinician

53. The Challenges of Working With Those
Affected by Trauma
 Burnout
 Compassion Fatigue
 Vicarious Trauma

54. 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 or
questioning of others’ intentions.
 Clinician may become overly concerned with safety of self and
consumers or may become numb to sense of danger and miss
signs of risky behavior for self or consumers.
 Can affect clinician’s connection to others and relationship
with spiritual beliefs. Decreased sense of hope.
 Physical and emotional exhaustion.
(Harris & Fallot, 2001)

55. Risks for Increased
Trauma 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 typical
trauma-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 unconsciously
deny or avoid exploring trauma

56. Possible Work Factors that Increase the Impact of
Trauma Work
 Work with consumers where concrete signs of success may be
few
 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 as
occupation 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)

57. Possible Individual Factors that Increase the
Impact of Trauma Work
 Personal history
 Personality
 Current personal circumstances
 Level of professional development
 High ideals/ rescue fantasies/ over-investment in meeting
all of client’s needs. Those most vulnerable to ITW may
view themselves as saviors or rescuers
 Working without supervision and/or consultation
 Poor support network
 Personal style of coping
(Figley, 1995; Rose, 2007)

58. Individual Ways to Reduce the ITW
 Psychological:
 Sustain balance between work and play
 Effective relaxation time and methods
 Using meditation or spiritual practice that is
calming
 Self assessment and self awareness
 Frequent contact with nature or other calming stimuli
 Methods for creative expression
(Rose, 2007)

59. Individual Ways to Reduce the ITW
 Physical:
 Body work: Monitoring parts of your body for tension and
using methods to release tension
 Healthy sleep schedule
 Healthy nutrition
(Rose, 2007)

60. Individual Ways to Reduce the ITW
 Social/Interpersonal:
 Social supports: At least 5 people, including 2 at work, who
will be highly supportive when called on
 Getting help: Knowing when and how to access help, both
informal and formal
 Social activism: Being involved in social justice activities to
address injustice
(Rose, 2007)

61. 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 accepting
those you can not
(Rose, 2007)

62. 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)

63. Wisdom for the Journey
Hope is not believing that we can change things.
Hope is believing that what we do makes a difference.
Vaclav Havel

64. Tim Welsh LCSW
twelsh@fhclouisville.org
502 569 1662

65. Trauma Screening
“Trauma screening refers to a
brief, focused inquiry to determine
whether an individual has experienced
specific traumatic events.”
(Harris & Fallot, 2001)

66. Trauma Screening
Two primary factors contribute to trauma concerns
being overlooked:
 Under-reporting of trauma by survivors
 Under-recognition of trauma by providers
(Harris & Fallot, 2001)

67. Under Reporting of Trauma
 Immediate safety concerns (i.e. fear of retaliation from
abusers)
 May fear stigma or responses that disbelieve or blame
the victim or pathologize attempts to cope with trauma
 Some feel ashamed about being victimized and the
attached sense of weakness
 Some, especially men, withdraw and isolate
 Childhood experiences may not be clearly remembered
(Harris & Fallot, 2001)

68. Under Recognition of Trauma
 Providers may feel uncomfortable asking about
trauma, fearing that they will not be able to manage the
response
 Providers may not want to ask because of lack of services to
address trauma concerns
 Providers may use vague or unclear terms that do not
correspond to consumer’s experience of past trauma (i.e.
violent physical abuse may be understood to have been
“discipline”)
(Harris & Fallot, 2001)

69. Reasons for Trauma Screening
 A main purpose is to identify effective follow-up and
referral, including determining need for immediate response if
risk of imminent danger exist.
 Screening demonstrates that agency identifies violence and
abuse as important events in the consumer’s life and that staff
are comfortable discussing trauma with consumers.
 Even if consumer declines to report, staff have initiated the
conversation and increased likelihood that consumer may
revisit trauma concerns later.
(Harris & Fallot, 2001)

70. 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)

71. Basics of Trauma Screening
 Complete screening with discussion of implications for
resources.
 Express appreciation for consumer participation and/or
consumer ability to self-protect by passing on questions or
ending discussion.
 Provide education and information regarding impact of trauma
as well as emphasize ability to heal from trauma as well as
resilience.
(Harris & Fallot, 2001)

72. Adverse Child Experiences Study
(ACE www.acestudy.org)