Adapting Trauma Treatment for Underserved Populations

1. Adapting Trauma Treatment forUnderserved Populations Margaret Charlton, Aurora Mental Health Center Ric Durity and Karen Mallah, Mental Health Corp of Denver The National Child Traumatic Stress Network 2003 All Network Meeting

2. How To Reach Us • Margaret Charlton: 303-326-3748 dr_charlton@yahoo.com • Ric Durity: 303-504-6715 rdurity@mhcd.com • Karen Mallah: 303-504-6500 kmallah@mhcd.com

3. Adapted Trauma Treatment Work Group • Subgroup for Deaf and Hard of Hearing • Subgroup for Developmental Disabilities • Future subgroups?

4. Goals for the Subgroups • Develop a paper outlining known facts about treating each underserved population. • Develop general guidelines for adapting phased trauma treatment. • Review the assessment methods used by the National Network and suggest adaptations for special populations as needed. • Adapt specific trauma treatment tools used by the National Network.

5. Challenges in Conceptualization • Differences between our initial populations. • People that are deaf/hard of hearing define their own culture. • They do not see themselves as having a disability or being handicapped. • Developmental disability is defined externally by the people providing treatment rather than the people who make up the population. • These differences result in major challenges for the work group in trying to be fair and non-judgmental in our approach to the needs of both populations.

6. Today’s Presentation • Describe the culture and needs of people who are deaf/hard of hearing and those with developmental disabilities. • Discuss how therapists and agencies can respond to these needs: • Education • Training • Reduction in prejudice

7. Goals • Describe factors related to developmental disabilities and deafness that increase the incidence of trauma for these populations. • Discuss methods of modifying traditional trauma treatment to better meet the needs of children with developmental disabilities and children who are deaf/hard of hearing. • Describe aspects of cultural/linguistic isolation within the family/community and consider techniques for taking a culturally affirming approach in providing care.

8. Aurora Mental Health Center • Provides mental health services to more than 5,000 people annually. • Is consistently ranked among the best treatment centers in Colorado. • Operates 15 specialty clinics located in 7 Counseling Centers. • Also provides services in • 6 Residential Facilities • 9 Public Schools • 2 county Departments of Human Services • And in homes, foster homes and other community locations

9. Intercept Center • A collaborative program of Aurora Mental Health Center and Aurora Public Schools • Provides intensive child and family services, including day treatment • Addresses the Special Education and Mental Health needs of children dual diagnosed with mental illnesses and developmental disabilities • Virtually all children receiving services at Intercept also have a history of trauma–Triple Diagnosis!

10. Developmental Disabilities • The concept of disability or lack of certain desirable characteristics is interwoven throughout the definition of the population and the nature of most treatment recommendations. • The population is defined externally, by caregivers and treatment providers, rather than the people involved.

11. Isolation vs. Inclusion • Many think of people with developmental disabilities living with their families in relative isolation or living in institutions. • Today most people with developmental disabilities are part of a community, participating in: • Vocational and residential opportunities through their Community Centered Boards • Recreational activities through groups like Special Olympics • Advocacy activities with their local ARC groups

12. Culture • As inclusion in groups with similar interests and needs increases, cultural norms and expectations are developing in a variety of areas: • Social • Vocational • Residential • Recreational

13. White Paper on Developmental Disability • A current operational definition • Statistical information regarding the incidence of trauma (and degree of under-reporting) • Special characteristics that may: • Influence the incidence of trauma • Increase the effect of the trauma • Suggestions for modification of evaluation and therapy

14. Background Information • In the US about 5 million people meet DD criteria • People with DD are 2-4 times more vulnerable to trauma than the general population • They are less likely to be identified as needing trauma treatment even though they generally have more negative symptoms than others following trauma • They are unlikely to receive appropriately adapted trauma treatment

15. Paper on Adapting Trauma Treatment • Reviews background information presented in the White Paper. • Discusses an initial approach to adaptation of trauma treatment. • Suggests specific modification to treatment to make it more accessible to people with developmental disabilities.

16. Assumption Check • Many different types of therapy have been found to be effective in treating people with developmental disabilities. • Although it generally takes longer for people with developmental challenges to make changes, those changes are stable once made. • People with developmental disabilities are less likely to recover spontaneously from trauma without treatment.

17. Information All Therapists Need • It is important that normal trauma responses not be attributed to the person’s developmental disability or pre-existing mental illness. • Children with developmental disabilities generally have the same types of symptoms following trauma that anyone else would: sleep disturbance, startle response, numbing, emotional constriction, disrupted sense of safety, shattered self-identity, etc.

18. Basic Modifications to Therapy Work • Slow down your speech. • Use language that is comprehensible to the client. • Use visuals whenever possible to reinforce verbal messages. • Present information one item at a time. • Be specific in making suggestions for change. • Practice different ways of handling situations. • Repeat key information.

19. Phase Oriented Trauma Treatment • Phase 1: Acknowledgment • Phase 2: Establish safety and build competency • Phase 3: Process trauma • Phase 4: Transition beyond the trauma

20. Vignettes • These stories are in an early stage of development. • They are designed to help therapists think about the special needs of clients with developmental disabilities at various phases of trauma treatment. • So far we have only worked on stories and adaptation for clients functioning in the mild range of retardation and older children/adolescents. • Further work will address strategies for meeting the needs of younger clients and those with lower cognitive functioning.

21. Phase One: Acknowledgment • Developmental disabilities may result in: • Greater difficulty completely understanding the traumatic event. • Misunderstandings of the event that increase stress. • A greater tendency of victims to blame themselves. • Caregivers play a large role in the lives of people with developmental disabilities and must be educated regarding normal reactions to trauma. • Treatment providers must remember that the developmental disability itself has probably resulted in prior traumatizing events.

22. Phase Two: Safety and Competency Safety: • Be sure all aspects of the environment are safe—home, community and school. • Address any unsafe conditions, even if they existed prior to the trauma. • Teasing and bullying at school or in the community • Family issues like anger management • Be sure all members of the treatment team are committed to safety and using the same language. • Work on re-establishing normal sleep patterns as soon as possible. • Facilitate a return to normal activities.

23. Phase Two Continued Competency: • Lack of control is a key issue for people with developmental disabilities and this issues is likely to be exacerbated by trauma • The disability generally results in many situations where the client feels disempowered, which must be addressed • Develop new skills as necessary: • Assertiveness • Ability to access help • Support networks • For people with developmental disabilities generalization of skills to new settings is very difficult, so practice and rehearsal are necessary.

24. Phase Three: Processing the Trauma • Be prepared to use tools for processing trauma that are appropriate to the child’s developmental rather than chronological age. • Help the child to process the trauma using play, art therapy, social stories, etc. • Use concrete metaphors and visual stimuli to compensate for processing difficulties. • Discuss using new competencies to counteract feelings of helplessness (remember how hard generalization is). • Address which aspects of the trauma were worst for the client (don’t assume you know).

25. Phase Three: Continued • Be prepared to address common post trauma issues: • Fear of reoccurrence • Guilt about the event • Loss and grief reactions • Separation anxiety triggered by the trauma

26. Phase Four: Transition • Move from working on the trauma to using the new knowledge and skills in normal life. • Discuss how the new knowledge will help in day to day life. • Process lessons learned in the trauma work. • Practice new skills until the client is confident of her/his ability to use them in all appropriate situations.

27. New Directions • People with developmental disabilities are more likely than others to be exposed to trauma. • They are more likely to experience profound negative effects on mental health following trauma. • We need to work together to develop effective treatments to meet this need.

28. References • Avrin, S., Charlton, M., & Tallant, B. (2002). Diagnosis and treatment of clients with developmental disabilities. [Original presentation 1998, revised 2002]. In Aurora Mental Health Center Staff Training Seminars. • Bütz, M. R., Bowling, J. B., & Bliss, C. A. (2000). Psychotherapy with the mentally retarded: A review of the literature and the implications. Professional Psychology: Research and Practice, 31(1), 42-47. • Charlton, M. (October, 2002). Relationships: One step at a time. In National Association for Dual Diagnosis Conference Proceedings: 19th Annual Conference. Kingston, New York: NADD Press. • Charlton, M. & Tallant, B. (October, 2003). Trauma Treatment with Clients Who Have Dual Diagnoses: Developmental Disabilities and Mental Illness. In National Association for Dual Diagnosis Conference Proceedings: 20th Annual Conference. Kingston, New York: NADD Press. • Mansell, S., & Sobsey, D. (2001). Counseling people with developmental disabilities who have been sexually abused. Kingston, New York: NADD Press.  • Pynoos, R. S., & Nader, K. (1988). Psychological first aid and treatment approach to children exposed to community violence: Research implication. Journal of Traumatic Stress, 1(4), 445-473.

29. Members of the Subgroup onDevelopmental Disabilities • Margaret Charlton, PhD, Chair • Matt Kliethermes, PhD • Brian Tallant, MS • Amy Tishelman • Anne Taverne

30. Acknowledgments This work on adapting trauma treatment for children with developmental disabilities would not have been possible without support from the National Child Traumatic Stress Network, the Aurora Mental Health Center including Randy Stith, PhD, CEO, Frank Bennett, Ph.D., Director of Children's Services and Brian Tallant, Intercept Center Program Director.