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Trauma-Informed Care Empowering. Engaging. Effective. Joann Stephens Stable Life, Inc. Trauma-Informed Care. What it is: a philosophical shift What it is not: an intervention to address PTSD **************************************** What happened to you? vs. What’s wrong with you?.

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Trauma-Informed Care Empowering. Engaging. Effective. Joann Stephens Stable Life, Inc.

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Trauma-Informed Care

Empowering. Engaging. Effective.

Joann StephensStable Life, Inc.

Trauma-Informed Care

What it is:a philosophical shift

What it is not:an intervention to address PTSD


What happened to you?


What’s wrong with you?

Statistics, or “How bad is it, really?”

56% of the general population reported at least

one traumatic event(Kessler,1995)

90% of mental health clients have been exposed

to a traumatic event and most have multiple

experiences of trauma(Muesar, 1998)

83% of females and 32% of males with

developmental disabilities have experienced

sexual assault. (Hard, 1986) Of those who were

assaulted, 50% had been assaulted 10 or more

times(Sobsey and Doe, 1991)

Psychological Trauma - What is it?

Trauma refers to extreme stress (e.g., threat to life, bodily integrity or sanity) that overwhelms a person’s ability to cope.

The individual’s subjective experience determines whether or not an event is traumatic.

Traumatic events result in a feeling of vulnerability, helplessness and fear.

Traumatic events often interfere with relationships and fundamental beliefs about oneself, others and one’s place in the world.

(Giller, 1999; Herman, 1992)

Psychological Trauma - Examples

Violence in the home, personal relationships, workplace, school, systems/institutions, or community

Maltreatment or abuse: emotional, verbal, physical, sexual, or spiritual

Exploitation: sexual, financial or psychological

Abrupt change in health, employment, living situation over which people have no control

Neglect and deprivation

War or armed conflict

Natural or human-caused disaster

Mediating or Exacerbating Factors


Age / developmental stage

Past experiences and coping skills

Cultural beliefs


Presence of sensitive caregiver

Supportive response

Culture and cultural beliefs


Severity & chronicity

Interpersonal vs. act of nature

Intentional vs. accidental

Acute Trauma – PTSD / Acute Stress Disorder

  • Re-experiencing - disturbing memories, dreams, flashbacks, intense psychological or physiological distress

  • Avoidance/ Numbing -avoidance of thoughts, feelings, people, places, & activities; feelings of detachment and amnesia; sense of a limited future

  • Arousal - irritability, angry outbursts, difficulty concentrating, hyper-vigilance, increased startle response, sleep problems

Complex Trauma / Complex PTSD / Developmental Trauma Disorder

Result of traumatic experiences that are interpersonal, intentional, prolonged and repeated

Symptoms of Complex Trauma

Re-experiencing Avoidance/ Numbing Arousal


  • Emotional difficulties:managing feelings; chronic anxiety; empathizing; low frustration tolerance; expressing needs, thoughts, concerns using words

  • Cognitive difficulties: cognitive biases; understanding what is being said; doing things in logical sequence; seeing ‘gray’; working with time; multiple ideas simultaneously; maintaining focus

  • Social difficulties: attending to or accurately assessing social cues; connecting with others; seeking attention in appropriate ways; appreciating how behavior impacts others

  • Handling transition and change: impulsive; adapting to change; handling unpredictability, ambiguity, uncertainty & novelty

Sanctuary Trauma

The overt and covert

traumatic events that

occur in various


  • mental health &

    substance abuse


  • foster care

  • corrections

  • medical

  • educational

  • religious

  • workplace

“I had been coerced into treatment by people who said they were trying to help…These things all re-stimulated the feelings of futility, reawakening the sense of hopelessness, loss of control I experienced when being abused. Without exception, these episodes reinforced my sense of distrust in people and the belief that help meant humiliation, loss of control, and loss of dignity.”

Vicarious or Secondary Trauma

The experience of learning about another person’s trauma and experiencing trauma-related distress as a result of this exposure

Adverse Childhood Experience (ACE) Study


Psychological (by parents)

Physical (by parents)

Sexual (anyone)

Physical neglect

Emotional neglect

Household with:

Substance abuse

Mental illness


Domestic violence

Imprisoned household member


ACE Score = Trauma “Dose”

Number of individual types of adverse childhood experiences were summed…

ACE scorePrevalence





4 or more16%

As ACEs , problems :

  • alcoholism and alcohol abuse

  • illicit drug use

  • risk for intimate partner violence

  • eating disorders

  • multiple sexual partners

  • smoking

  • suicide attempts

  • chronic obstructive pulmonary disease (COPD)

  • depression

  • ischemic heart disease (IHD)

  • liver disease

  • sexually transmitted diseases (STDs)

  • obesity

  • health-related quality of life

Impact of Trauma Over the Life Span

Effects of childhood

adverse experiences:

  • neurological

  • biological

  • psychological

  • social

Beginning to Understand‘Disrupted Neurodevelopment’

  • Fight: resist

  • Flight: run away

  • Freeze: stay still

The Stress Response and the Brain

If there is danger the ‘thinking brain’ shuts down, allowing the doing brain to act.

Autonomic and Parasympathetic Nervous System

  • Increase HR and blood pressure

  • Tunnel vision

  • Event recorded in “high definition”

  • Increased cholesterol

  • Pain sensation dulled – natural morphine (endorphins)

  • Increased alertness, increased focus

  • Insulin increases

  • Memory loss from parts of the event

  • Increased strength, energy, aggression

  • Hearing may shut down

  • Time slows down or speeds up

    (Susan A. Storti, 2008)

Immediate Aftermath of Abuse

What you may see:



Shut down / numb


What you may not see:


Guilt / Shame



Potential Triggers

Lack of control-powerlessness

Threat or use of force

Observing threats, assaults, others engaged in self-harm


Physical restraints – handcuffs, shackles

Interacting with authority figures

Fear based on lack of information

Lack of privacy

Removal of clothing – strip searches, medical exams

Being touched – pat downs

Being watched – suicide watch

Loud noises


Intrusive or personal questions

Being in a locked room

Institute for Health and Recovery




Past Present

E - A Large Event

e - A Small Event

R - A Large Reaction

Complex Trauma – Impact on Development

Impact on WorldviewTypical Development vs. Developmental Trauma

Nurturing & stable attachments with adults

Belief in a predictable & benevolent world/ generally good things will happen to me

Feeling of positive self-worth /others will see my strengths

Optimism about the future

Feeling that I can have a positive impact on the world

Basic mistrust of adults/inability to depend on others

Belief that the world is an unsafe place/bad things will happen & they are usually my fault

Assumption that others will not like me

Fear & pessimism about future

Feelings of hopelessness & lack of control

Understanding Behaviors: Explanation vs. Excuse

  • External defense

    • Anger / defiance

    • Violence towards others

    • Truancy

    • Criminal acts

  • Internal defense

    • Withdrawal

    • Substance use

    • Eating Disorders

    • Violence to self

    • Dissociation

Reenactment Behaviors

Certain behaviors can cause caregivers to feel negative and hopeless about the person they work with

People generally do not consciously choose to repeat the patterns of painful relationships

Are familiar and have helped in the past

‘prove’ the person’s negative beliefs

Help vent frustration, anger and anxiety

Give a sense of mastery over the old traumas

Shame and Humiliation

The basic psychological

motive or cause of violent

behavior is the wish to

ward off or eliminate the

feelings of shame and

humiliation – a feeling that

is painful and can even be

intolerable – and replace

it with a feeling of pride”

(Gilligan, 2004)

Impact of Trauma on World View

The world / environment is unsafe

Other people are unsafe and cannot be trusted

My own thoughts and feelings are unsafe

I expect crisis, danger and loss

I have no self-worth and no abilities

Our labels don’t describe the complex interrelated, physical, psychological, social, and moral impacts of trauma …and they rarely help us know what to do to help.-- Bloom

  • Dissociative Disorder

  • Somatoform Disorder

  • Anxiety Disorder

  • Major Depression

  • Borderline Personality Disorder

  • Substance Abuse Disorder

  • Post Traumatic Stress Disorder

  • Attention Deficit Hyperactivity Disorder

  • Conduct Disorder

  • Bipolar Disorder

  • Attachment Disorder

  • Autistic Disorders

Trauma-Informed Care – What is it?

Incorporate knowledge about trauma –

prevalence, impact, and recovery – in all aspects

of service delivery

Place priority on:

  • meaningful consumer engagement

  • physical and emotional safety

  • choice

  • collaboration / sharing power

  • empowerment and skill building

  • healing relationships

    Increase caregiver capacity

Guiding Values of Trauma-Informed CareHealing Happens in Relationship

What does it look like?


  • Key Question: ‘What’s wrong with you?’

  • Service providers are the experts on the lives of consumers

  • Therapy sessions and specific interventions are viewed as the primary method of treatment

Trauma- Informed

  • Key Question: ‘What has happened to you?’

  • Consumers are the experts on their lives and benefit from a partnership with providers

  • Healing happens in healthy relationships

Comparison of Systems (cont’d)


  • Decreasing symptoms viewed as success

  • Rules, directives, and use of token systems as primary approaches to maintaining order


  • Symptoms viewed as

    adaptations and ways to cope to trauma.

    Healing process may

    temporarily worsen symptoms

  • Motivational interviewing, lower brain interventions, and compassionate communication are tools used to maintain healing relationships

Practice Based on TIC ValuesValue: Pursue the person’s strengths, choice and autonomy


1. Everyone goes to bed at 10:30 pm and lights out

2. Person is given completed treatment plan which must be signed for services

3. A few homogenous activities are provided and everyone is supposed to attend


1. A range for bedtime that identifies and adapts to individuals difficulty with night-time, bedrooms, and different bio-rhythms

2.Recovery plans are created collaboratively; family members or advocates are included if the consumer so chooses

3.A variety of activities are offered and consumers are provided a menu of options based on needs, desires and recovery plan

General Tips

Think about the possibility of trauma as underlying problem – helps to diminish frustration

History of physical violations may create hypersensitivity about bathing, changing clothes, physical exams - do what’s possible to help people feel in control

Recognize issue of trust and betrayed trust will be a major, ongoing issue

If you cannot understand why someone does or doesn’t do something that seems to be common sense, be curious

(Bloom, 2009)


  • Greater consumer satisfaction

  • Increased recovery rates

  • Reduced consumer retraumitization

  • Lower rates of consumer and staff assault and injury

  • Lower rates of staff turnover and higher morale


    • Pennsylvania State Hospitals

    • Massachusetts Dept. of Mental Health

    • Fallot & Harris, Using Trauma Theory to Design Service Systems

    • Mendota Mental Health Institute, Wisconsin

Sample of Models, Guides and Resources

The Anna Institute.

Developing Trauma-Informed Organizations, Inst. for

Health and Recovery.

Risking Connection, Sidran Institute.

The Sanctuary Model, CommunityWorks.

Using Trauma Theory to Design Service Systems,

Community Connections.


  • Sandra Bloom, Creating Sanctuary

  • Roger Fallot & Maxine Harris, Using Trauma Theory to Design Service Systems

  • Charles Figley, Compassion Fatigue

  • Esther Giller, Sidran Foundation

  • Judith Herman, Trauma and Recovery

  • Bruce Perry,

    Multiple slides were taken from the work of…

  • National Center for Trauma Informed Care,

  • Roger Fallot, Wisconsin TIC presentations

  • Vince Fellitti and Rob Anda (ACE study)

Contact Information

Elizabeth Hudson, LCSW

Trauma-Informed Care Consultant

WI Dept. of Human Services

Division of Mental Health and Substance Abuse Services


Employed by University of Wisconsin -

School of Medicine and Public Health

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