Trauma-Informed Care: Part Two

Transcription

1 2011 National Healthcare for the Homeless Council Regional Training Detroit, MI Trauma-Informed Care: Part Two Laurie S. Hardin, MSSW Louisville, KY September 20, 2011

2 Traumatic Stress: Review Persistent trauma impacts physical, emotional, relational, and cognitive functions. Trauma overwhelms ability to cope. Behaviors are adaptations to past threats. Homelessness and trauma are interrelated. Adapted from Volk, Guarino & Konnath (2007). HRC s Homelessness and Traumatic Stress Training Package.

3 Training Goals Define trauma-informed services Identify key principles of trauma-informed care Learn how to apply those principles to our work Compare trauma-informed vs. traditional service provision

4 Impact of Trauma: Client World View The world is an unsafe place to live in. Clients anticipate continued crises, danger and loss. Other people are unsafe and cannot be trusted. Adapted from Volk, Guarino & Konnath (2007). HRC s Homelessness and Traumatic Stress Training Package.

5 Impact of Trauma: Client World View The client s own thoughts and feelings are unsafe. Lack of belief in self-worth and capabilities. Bad... Sad... Mad... Been had. Adapted from Volk, Guarino & Konnath (2007). HRC s Homelessness and Traumatic Stress Training Package.

6 Client World View & Services How does the client world view impact how the client accesses services? What challenges might consumers face in accessing services?

7 Difficulties Encountered Within Systems of Care Fragmented, unresponsive systems lead to: Long waits and wait lists. Red tape confusing instructions, lack of information about options. Lack of communication among service providers. Adapted from Volk, Guarino & Konnath (2007). HRC s Homelessness and Traumatic Stress Training Package.

8 Difficulties Encountered Within Systems of Care Re-traumatization: Lack of respect and safety and an absence of control and choice that mimics past traumatic experiences. Adapted from Volk, Guarino & Konnath (2007). HRC s Homelessness and Traumatic Stress Training Package.

9 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 Result in failure to make appropriate referrals

10 What Does it Mean to Be Trauma-Informed?

11 Trauma-Informed Care is a strengths-based framework that is grounded in an understanding of and responsiveness to the impact of trauma, that emphasize 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, E., Bassuk, E., & Olivet, J. (2007). Shelter from the Storm: Creating Trauma-Informed Homeless Services. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration. Available at

12 Principles of Trauma-Informed Care

13 Principles of Trauma-Informed Care Choice & Empowerment Strengths-Based Approach Emphasis On Safety Trauma Awareness

14 Strengths-Based Approach Recovery is possible Focus on strengths Recognize resiliency

15 Principles of Trauma-Informed Care Choice & Empowerment Strengths-Based Approach Trauma Emphasis On Safety Awareness

16 Trauma Awareness Program Mission & Policies Trauma Lens Integration of Services Staff Support, Supervision & Self-Care

17 Program Mission & Policies Written policies acknowledge impact of trauma Hire staff with an understanding of trauma Emphasize consumer involvement & collaboration Commitment to delivering trauma-informed services and exercising universal precautions

18 Universal Precautions We create systems of care that are traumainformed on the assumption that the consumers we serve have a history of traumatic stress.

19 Trauma Lens Use of trauma-informed language Trauma screening and assessment Access to trauma-specific services

20 What happened to you? vs. What is wrong with you?

21 What need does this meet? vs. Why would you do this?

22 Survivor vs. Victim A Manic-Depressive vs. Individual diagnosed with bipolar disorder Non-compliant vs. difference in priorities & goals Whiney vs. seeking assistance

23 Trauma Screening Identifies appropriate follow-up and referral, including issues of imminent danger Increases knowledge and awareness of trauma for both staff and consumers Establishes understanding that trauma matters Fallot RD & Harris M (2001). A trauma-informed approach to screening and assessment. In Fallot & Harris (Eds.). Using trauma theory to design service systems. Jossey Bass: San Fransisco.

24 Trauma Screening Brief, focused screening Questions are clear and specific Adequate staff and consumer preparation Maximize consumer choice and control Conclude with implications for follow-up services Fallot RD & Harris M (2001). A trauma-informed approach to screening and assessment. In Fallot & Harris (Eds.). Using trauma theory to design service systems. Jossey Bass: San Fransisco.

25 Trauma Assessment More detailed exploration of nature & severity of trauma history Assessment of present trauma-related symptoms; May contribute to formal mental health diagnosis Provider assist with helping consumer build skills for containment, including grounding and centering Discussion of trauma specifics develops over time and as trust is built- first goal is safety Fallot RD & Harris M (2001). A trauma-informed approach to screening and assessment. In Fallot & Harris (Eds.). Using trauma theory to design service systems. Jossey Bass: San Fransisco.

26 Trauma-Specific Services Differ from and are extension of trauma-informed care services Specifically address the impact of trauma with the goal of reducing symptoms and enabling recovery Give consumers access to trauma-specific services Hopper, E., Bassuk, E., & Olivet, J. (2007). Shelter from the Storm: Creating Trauma-Informed Homeless Services. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration. Available at

27 Trauma-Specific Services Some well-known trauma-specific interventions: Risking Connection Sanctuary Model Seeking Safety Trauma, Addictions, Mental Health, and Recovery (TAMAR) Model Trauma Recovery and Empowerment Model (TREM and M-TREM)

28 Integration of Services Research indicates that service settings that offer integrated counseling to address mental health, trauma, and substance use concerns have better outcomes than services that were not integrated Cocozza JJ, Jackson EW, Hennigan K. (2005). Outcomes for women with co-occurring disorders and trauma: Program-level effects. Journal of Substance Abuse Treatment, 28

29 Staff Training & Support Photo credits: K. Volk

30 Staff Training & Support Training opportunities Sustainability: Trauma issues are revisited with ongoing education and discussion Supervision Staff empowered to have program input Adapted from Volk, Guarino & Konnath (2007). HRC s Homelessness and Traumatic Stress Training Package.

31 Staff Training & Support Agency administration and staff recognize of the impact of trauma work and the need for self-care.

32 The Impact of Trauma Work Burnout: Physical or emotional exhaustion, especially as a result of long-term stress. Compassion Fatigue: A state of tension and preoccupation with individual or cumulative trauma of clients. Vicarious Trauma: The transformation or change in a helper s inner experience as a result of responsibility for an empathic engagement with traumatized clients. Figley CR (1995). Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. New York: Brunner/Mazel. ; McCann IL & Pearlman LA (1990). Vicarious traumatization: A framework for understanding the psychological effects of working with victims. Journal of Traumatic Stress, 3,

33 The Impact of Trauma Work Professional Quality of Life Screening Compassion Satisfaction: l The positive aspects of helpingpleasure and satisfaction derived from working in helping, care giving systems Vicarious Resilience: is the process of clinicians learning about overcoming adversity from the trauma survivors they work with the resulting positive transformationand empowerment in those clinicians through their empathic engagement with the stories of trauma and resilience of their clients (like VT but in a positive healing direction Berthold, S.M. (2011). PPT presentation: Serving survivors of trauma: Attending to vicarious trauma and enhancing vicarious resilience. Available at Huddnall Stamm, B. 2009, D., Hernandez, P., & Gangsei, D. (2008). Vicarious resilience: A qualitative investigation into its description. Traumatology,14(3), ;Hernández, P., Gangsei, D., & Engstrom, D. (2007). Vicarious resilience: A new concept in work with those who survive trauma. Family Process, 46,

34 Staff Self-Care Know triggers & warning signs. Be alert to what you expose yourself to outside of work. Set boundaries. Add variety to your work. Maintain your relationships outside of work. Build self-care into your routine at work and at home. Adapted from Volk, Guarino & Konnath (2007). HRC s Homelessness and Traumatic Stress Training Package.

35 Principles of Trauma-Informed Care Choice & Empowerment Strengths-Based Approach Emphasis On Safety Trauma Awareness

36 Emphasis on Safety Physical & Emotional Safety Safe Relationships Crisis Prevention Plan Avoid Re-Traumatization Cultural Competence

37 Physical Safety Calming environment Proper lighting Access to exits Sufficient space Attention to signs Others?

38 Emotional Safety Respect & Validation Feeling Heard & Understood Sense of Empathy Genuine Concern Consistency & Predictability Others?

39 Past Experience of Trauma in Relationships What may be the experience of emotional and physical safety in the trauma survivor s previous relationships? What is the experience of power and control?

40 Power & Control Betrayal Hierarchical Boundaries Secrecy Silenced or Unheard Voice Powerlessness Abuser s Constructed Reality Adapted from Petersen, S. (2011). Trauma-Informed Care Powerpoint presentation. NHCHC.

41 Healing happens in relationship

42 Safe Relationships & Trustworthiness We work to establish relationships with people who may have been humiliated, hurt or betrayed by those who are supposed to protect and love them. What are the challenges in engaging people when providers have proven untrustworthy in the past? What responsibilities do we have when engaging people in relationship? Adapted from Petersen, S. (2011). Trauma-Informed Care Powerpoint presentation. NHCHC.

43 Safe Relationships 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 Adapted from Schilling, K. Trauma-Informed Care for Individuals Who Are Homeless. Power point presentation at Phoenix Health Center, March 2010.

44 Safe Service Relationships Begin the new service relationship with an open question about what the consumer wants and what might help to make the consumer feel comfortable and safe. Establish clear boundaries about roles. Be consistent. To be trustworthy, we need to do what we say we are going to do. Own mistakes, acknowledge them and fix mistakes when possible (be the opposite of the perpetrator).

45 Crisis Prevention Plan What & Why?

46 Crisis Prevention Plan What: A person-specific plan developed proactively by consumer and provider before a crisis occurs A therapeutic process A trauma sensitive task A consumer-owned plan written in easy to understand language Glover, R.W. & Sims, B. Trauma Sensitive Tools. NASMHPD

47 Crisis Prevention Plan Why: Assist consumers to identify coping skills before they are needed Early intervention to help prevent crisis Assist provider to plan ahead and know what to do if situation escalates Help staff use interventions that reduce risk and trauma to individuals Glover, R.W. & Sims, B. Trauma Sensitive Tools. NASMHPD

48 Crisis Prevention Plan Essentials: Identify Triggers Note Early Warning Signs Develop Strategies for Stabilization

49 Early Warning Signs A physical sign of distress that is a precursor or manifestation of upset: Restlessness Agitation Pacing Shortness of breath Bouncing legs Loud voice Clenching fist Rocking Spacing out Crying Glover, R.W. & Sims, B. Trauma Sensitive Tools. NASMHPD

50 Crisis Prevention Strategies Person-specific calming activities to minimize and manage stress: Time away from situation Listening to music Talking to safe person Lying down Working out Coloring or crafts Deep breathing Journaling Doing a puzzle Stretching Glover, R.W. & Sims, B. Trauma Sensitive Tools. NASMHPD

51 Avoid Re-Traumatization Establish safety first Build skills Provide information Maximize sense of control Minimize exposure to triggers

52 Cultural Competence

53 Principles of Trauma-Informed Care Choice & Strengths-Based Approach Empowerment Emphasis On Safety Trauma Awareness

54 Choice & Empowerment Choice & Control Consumer Involvement & Collaboration

55 Choice & Control Co-creation of written and monitored individual goals helps consumers take control over their lives and their ideas about the future Underscore consumer choice and control of recovery. Respect autonomy. Help consumers build skills and focus on strengths. Increases confidence, self-esteem, and self-efficacy Adapted from Volk, Guarino & Konnath (2007). HRC s Homelessness and Traumatic Stress Training Package.

56 Consumer Collaboration Maximize collaboration and sharing of power between staff and consumers. Involve consumers in design and evaluation of services. Hire consumers to provide peer support and advocacy.

57 How Do Trauma-Informed Services Differ From Traditional Services?

58 Comparing Approaches Traditional Lack of education on trauma prevalence & universal precautions Trauma-informed Recognition of high prevalence of trauma Cursory or no trauma assessment Over-diagnosis of schizophrenia, bipolar disorder, conduct disorder & addictions Rule enforcers- focus on compliance Assess for traumatic histories & symptoms Recognition of primary and co-occurring trauma diagnosis Caregivers/supportersfocus on collaboration Adapted from Understanding Trauma: When Bad Things Happen to Good People. SAMSHA (2011)

59 Comparing Approaches Traditional Tradition of Toughness valued as best care approach Keys, security uniforms, staff demeanor, tone of voice Patient-blaming as fallback position without training Behavior seen as intentionally provocative Trauma-informed Recognition of culture and practices that are retraumatizing Power & control minimizedconstant attention to culture Address staff training needs to improve knowledge & sensitivity Staff understand function of behavior as adaptive Adapted from Understanding Trauma: When Bad Things Happen to Good People. SAMSHA (2011)

60 Comparing Approaches Traditional Reactive- Services and symptoms are crisis driven and focused on minimizing liability. Trauma-informed Pro-active- Preventing further crisis and avoiding retraumatization. Sees clients as broken, vulnerable and needing protection from themselves. People providing shelter and services are the experts. Understands providing choice, autonomy and control is central to healing. Consumers are active experts and partners with providers Adapted from Understanding Trauma: When Bad Things Happen to Good People. SAMSHA (2011)

61 Research: Outcomes of Trauma-Informed Services Better outcomes for adults and children. Positive effect on housing stability. Decrease in crisis-based services. Cost-effective. Positive responses from providers. Positive responses from consumers. Hopper, E., Bassuk, E., & Olivet, J. (2007). Shelter from the Storm: Creating Trauma-Informed Homeless Services. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration. Available at

62 Next Steps Applying Principles to Your Work Initiating Organizational Change Working for Systemic Change

63 Inspiration for the Journey People are often unreasonable, illogical, and self-centered; Forgive them anyway. If you are kind, people may accuse you of selfish, ulterior motives; Be kind anyway. If you are successful, you will win some false friends and some true enemies; Succeed anyway. If you are honest and frank, people may cheat you; Be honest and frank anyway. What you spend years building, some could destroy overnight; Build anyway. If you find serenity and happiness, they may be jealous; Be happy anyway. The good you do today, people will forget tomorrow; Do good anyway. Give the world the best you have, and it may never be enough; Give the world the best you ve got anyway. Mother Theresa had this on her wall