Philosophy of Care : Trauma-Informed Care. What is Trauma? Trauma is. What is Trauma? Types of trauma OBJECTIVES

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1 OBJECTIVES Philosophy of Care : Trauma-Informed Care A training presented by the (MHRI) for the Supportive Housing Providers Association (SHPA) Develop a common language to understand and discuss trauma and signs of trauma Explore the key components of trauma-informed care Review the importance of professional boundaries and self-care Explore feelings, attitudes and challenges of supporting trauma-informed services What is Trauma? Trauma is An event may be experienced as traumatic when it is sudden, unexpected, and perceived as dangerous An event may be experienced as traumatic when the individual feels overwhelmed by the event and unable to manage the daily business of life as a result We cannot predict who will be traumatized by events typically described as traumatic What is Trauma? Key Components of traumatic experiences: - Intense feelings of fear, helplessness, lack of control - Threat to one s physical or mental well-being through violence or threat of violence - Catastrophic responses Subjective and defined by the experience of the survivor Types of trauma Acute traumatic stress -generally involves one time traumatic experience (car accident or natural disaster) Complex trauma -prolonged or multiple traumatic events; often involving a caregiver or personal relationship (neglect, physical or sexual abuse)

2 PTSD vs. Complex Trauma PTSD (DSM-IV) Event(s) that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others. Complex Trauma (Herman, 1997) History of subjection to totalitarian control over a prolonged period subjected to totalitarian systems in sexual, domestic life. Examples: hostages, POWs, concentration camp survivors, survivors of some religious cults Victim of: Abuse Neglect Maltreatment Exposure to Trauma Witness: -See -Hear -Know Events that can be traumatic Lens of Trauma Sexual abuse Severe neglect Physical abuse Domestic violence Witnessed violence and cruelty to others Deprivation caused by extreme poverty Serious emotional and psychological abuse Repeated abandonment or sudden loss Rape (sexual assault) Substance use Homelessness Trauma comes in many forms including: community violence, poverty, personal violence, torture, loss of homeland, war, fear, homelessness, oppression, imprisonment, racism and environmental degradation. Trauma and Mental Illness Trauma and Substance Use Virtually universal trauma exposure (well over 90% report at least one traumatic event) Childhood sexual abuse: 52% of women and 35% of men Adult sexual assault: 64% of women and 26% of men Attacked with weapon in adulthood: 49% of men and 37% of women Witnessed killing or serious injury: 43% of men and 24% of women Physical and sexual abuse among women in substance abuse treatment programs is estimated to range from 40% to more than 90%, depending on definition of abuse and target population. (Moncrieff, et al.;1996; Najavits et al.: 1997; Rice et al. 2001; Root, 1989)

3 Trauma and Homelessness What does trauma feel like? Relationship between trauma and homelessness is bidirectional Homelessness is traumatic Homelessness can be a risk factor for re-traumatization and re-victimization In one study of the homeless population in Washington, DC, 63% of homeless women and 33% of homeless men reported having been abused by an intimate partner Intense fear Fear of complete destruction Total helplessness Profound emptiness Loss of control Total disconnection Traumatic events impact: Traumatic events impact: Feelings work on developing feeling vocabulary; manage feelings; connect to others Judgment access to insight, perspective, ability to see and weigh consequences; boundaries Beliefs what it means to feel safe, trust, have self-esteem, feel connected, and to feel in control and effective in our lives. Frame of reference identity (who am I?); world view (what is the world really like?); spirituality (what do I believe?) Memory & Perception --often fragmented; difficulty concentrating Body & Brain neurobiology -fight/flight response; survivors often feel the biological responses of fight/flight all the time, but can t act on it, leaving them in constant state of hyper-arousal, fear and anxiety; Medical chronic pain, GI distress; headaches. Assessment for Trauma What do signs or symptoms of trauma look like? Providers can increase the chances of improved outcomes for participants by following these steps: Screen for trauma Discuss the results Provide a referral Provide educational materials Follow up Everyone experiences trauma differently Survivors who exhibit trauma symptoms usually present in one of four ways: -Sad -Mad -Bad -I ve been had

4 Signs of Trauma What Do They Mean? Symptom Handout A trauma-informed model frames survivors symptoms as that person s best attempt to manage what they have experienced. What helps someone survive is a strength that person has learned and - in some way - continues to help in the present. Effects of Trauma Various factors impact effect of trauma -previous exposure to trauma -duration of the trauma -severity of the trauma -prior emotional/behavioral problems -response from caregiver/support system Why Trauma Informed? Misunderstood or ignored signs of trauma may: Interfere with help-seeking Limit engagement into services Lead to early drop out Inadvertently retraumatize people you are trying to help Other reasons? Basic Principles of Trauma-Informed Services (Harris & Fallot, 2001) Basic Principles of Trauma Informed Care Identify trauma as a defining experience that can shape a survivor s sense of self and others -Understand that problem behaviors started as understandable attempts to cope with trauma -Recognizes that such adaptations may be seen in a variety of life domains Recognize that trauma, homelessness, mental illness, substance use and other conditions are interwoven Recognize that the participant s response to trauma is an attempt to survive (a strength) what has been experienced, even when responses become problematic

5 A Trauma-Informed Framework Emphasizes A Trauma-Informed Approach Means: Respect validates survivor experiences; reduces shame; places priority on participant safety, choice and control; uses participant s language to talk about trauma; normalizes behaviors in a non-judgmental way; emphasizes resiliency in human responses to stress Information provides resources; supports participant empowerment & skill development Connection-healing power of relationships and being connected to others; open & collaborative Hope for participant and providers alike Asking participants about their experience of trauma; completing a trauma assessment. Developing service plans with trauma history in mind so that retraumatization is kept to a minimum. Recognizing and respecting when a participant is not ready to discuss trauma experiences. A Trauma-Informed Approach Means: A Trauma-Informed Approach Means: Offering trauma-informed interventions or access to such services. Assessing and planning for current safety needs. Acknowledging participants resilience as survivors and building on these skills. Providing participants opportunities to master their trauma experiences such that daily activities are not impacted. Recognizing the signs and symptoms of secondary, vicarious trauma and developing mechanisms to support staff. Revising policies and procedures to reduce barriers to providing services and employing trauma survivors. Best Practices Best Practices Be aware and sensitive to trauma and it s impact. Explain why you are asking about trauma experienced. Recognize when someone is becoming re-traumatized and provide needed supports. Assess current safety and collaboratively develop plans and skills to establish safety. Connect participant to community supports; build support network. Know your areas of expertise. If the participant chooses, establish connections to trauma specific services available in the community. Recognize trauma impacts individuals differently signs and symptoms of traumatic response may vary as well as onset of symptoms; many individuals exposed to traumatic events will not experience troublesome symptoms as a result of exposure. Ask the participant what support they have found helpful in the past. Acknowledge the resiliency needed to survive trauma and build on these skills and strengths.

6 What does all of this mean for our work? Traumatic events call into question basic human relationships. They breach the attachments of family, friendship, love and community. -Judith Herman What does all of this mean for our work? We work to establish relationships with participants who may have been humiliated, hurt and betrayed by those who are supposed to be counted on for safety and protection What are the challenges in engaging these participants when providers have proven untrustworthy in the past? What responsibilities do you have when engaging these participants in a relationship? The Role of Power in the Provider Relationship As a provider we hold power over the participant Participants who have experienced trauma have learned how to survive relationships with others who have more power so that they are able to get their needs met Expect the participant to tell us what we want to hear and do the right thing. We can model a new way. What is a Boundary? noun, plural -ries. 1. something that indicates bounds or limits; a limiting or bounding line. We draw invisible lines to set these limits: physically, emotionally, and verbally Boundaries are a necessary part of relationships Most traumatic events are an inherent violation of boundaries Why do we establish boundaries? Our assumptions on boundaries To develop relationships based on mutual respect that ensure safety, consistency and predictability Assume a participant s understanding of relationship norms might differ from yours Past history of trauma may cause a participant to look at a provider as an abuser this is what trauma has taught them

7 How do we establish boundaries? Building Trust and Being Trustworthy In conjunction with the participant we establish expectations for the relationship We act consistently and predictably We uphold our boundaries even when the participant challenges them (The participant may invite boundary violations that feel normal to them this is an opportunity to see how the participant views relationships) On-going process trust also reflects self-trust Assume distrust is earned and honor that distrust Own your mistakes, acknowledge them and fix mistakes when possible (be the opposite of the perpetrator) Myths about trust Myths vs. Reality of Trust Myth Reality Trust is soft. Trust is hard, real and quantifiable. Trust is slow. Nothing is as fast as the speed of trust. Trust is built solely on integrity. Trust is a function of both character and competence. You either have trust of you don t. Trust can be both created and destroyed. Once lost, trust cannot be restored. Though difficult, in most cases lost trust can be restored. You can t teach trust. Trust can be effectively taught and learned and it can become a leverageable, strategic advantage. Trusting people is too risky. Not trusting people is a greater risk. You establish trust one person at a time. Establishing trust with the one, establishes trust with the many. Burnout Challenges of working with survivors of trauma Vicarious Trauma Burnout Vicarious Trauma Caused by a lack of balance between the demands of the work environment and the provider s need for self-care and support Develops GRADUALLY. The enduring psychological consequences for therapists of exposure to the traumatic experiences of clients. Persons who work with survivors may experience profound psychological effects, effects that can be disruptive and painful for the helper and persist for months or years after the work with the traumatized person. (McCann and Pearlmann, 1990). Develops GRADUALLY

8 Assumptions and Silencing the Response Refers to the reaction and series of assumptions that guide the caregiver to: re-direct, shutdown, minimize, or neglect the traumatic material brought by the participant Can be active or passive: failing to assess for trauma and trauma symptoms or by recognizing the trauma and placing attention elsewhere Assumptions Assumptions: I cannot do anything about it anyway, bad things happen to bad people, I will be destroyed if I hear about the event or let it affect me, it is too terrible to be true, violates my worldview, I/participant just needs to get over it, if it can happen to this participant then it can happen to me, I am a bad person/helper. How do we silence ourselves and the participant? Cycle of Silence Avoiding the topic and changing the subject Providing pat answers Minimizing our distress or the participant s distress Faking interest or boredom Wishing the participant would get over it Angry or sarcastic with participant Humor to minimize Blaming self or participant for their experiences Not believing self or participant Worker silences the participant Supervisor silences the worker Worker silences the worker Community silences the Worker and the participant What Can You Do? Prevention and Management Normalize trauma Help the participant tell their story Link signs of trauma or images with past events Name feelings experienced Be curious and respectful of desire to talk about experiences Connect participants to others, peers, support, safety-net Be vigilant about safety develop a plan Know the signs Maintain boundaries Monitor caseloads Balance work activities Supervision, Supervision, Supervision Note resiliency in self and participants Holding hope for ourselves and participants Training

9 Three stages: Trauma-Specific Services Establishment of safety Remembrance and mourning Reconnection with everyday life (Herman, 1992) Trauma-Specific Treatment Models Addictions and Trauma Recovery Integration Model ATRIUM (Miller & Guidry, 2001) Helping Women Recover HWR (Covington, 1999) Seeking Safety (Najavits, 2002) Trauma Recovery and Empowerment Model TREM (Harris, 1998)

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