Kiersten Parker, Youth Advocate Tal Curry, DPH Program Administrator

1. Trauma Informed Care Overview FRYSC Fall Institute 2012 Kiersten Parker, Youth Advocate Tal Curry, DPH Program Administrator

12. When all she wants is…

13. Discussion

14. In the absence of formal recognition or diagnosis for complex traumatic stress disorders, there is the potential mis- or overdiagnosis of severe disorders (e.g., bipolar, schizophrenia spectrum disorders, borderline personality disorder, conduct disorder). (Christine Curtois and Julian Ford, “Treating Complex Traumatic Stress Disorders,” 2009)

15. Training Objectives • Raise awareness about the often unrecognized prevalence of trauma history • Stimulate thinking around how to take trauma exposure history into account so that… • We don’t re-traumatize • We establish response styles and physical surroundings that promote healing • We support a strength based perspective • To initiate a dialog which could transform service delivery toward a more trauma sensitive model of care

16. Overview • Definitions • Prevalence • Understanding Trauma: Its Consequences and Impact • Trauma Informed System of Care

17. Imagine... • A place where people ask ……. “what happened to you” instead of “what’s wrong with you?" • A place that understands that trauma can be re-triggered. • A place committed to supporting the healing process while ensuring no more harm is done.

18. Trauma is a Public Health Concern • “It has become more clear than ever psychological trauma is a primary — but often ignored or overlooked — factor of health (both physical and mental)... this presents a public health crisis in the United States that needs to be addressed immediately.” From a letter (9-29-06) to President Bush the House Bipartisan Caucus on Addiction, Treatment, and Recovery

19. What is Trauma Informed Care? • Service delivery that is directed by • an appreciation for the high prevalence of traumatic experiences in persons who receive mental health services • a thorough understanding of the profound neurological, biological, psychological and social effects of trauma and violence on the individual (Jennings, 2004)

20. What is System of Care? 1. A philosophy or framework about the way services should be delivered to children and families 2. A community-specific design built: • within this philosophy/framework • around local/state leadership, political context and funding • to fit with other initiatives and partnerships 3. Not a model, program or single definable thing

22. A Paradigm Shift • Not simply about trauma aware; but trauma informed • Shifts how we see our clients • What happened to you • Rather than what’s wrong with you • Shifts how we see their symptoms • Instead of focusing on what w are not good at, we focus on what we are good at • Shifts how we go about providing services—System of Care

23. What is trauma?

24. What is Trauma? • DSM IV-TR ----PTSD • Defines “traumatic event” as one in which “a person experienced, witnessed or was confronted with an event(s) that involved actual or threatened death or serious injury or threat to the physical integrity of self or others”. • The person’s response involved intense fear, helplessness or horror

25. Can you identify this picture?

26. How does this impact you?

27. What is trauma? • “Traumatization occurs when both internal and external resources are inadequate to cope with the external threat” (Van derKolk, 1989) • Trauma overwhelms the ordinary systems that give people a sense of control, connection and meaning. • Therefore...

28. Types of trauma resulting in serious persistent mental health problems: • Complex trauma- “a psychiatric condition that officially does not exist, but which possibly constitutes the most common set of psychological problems to drive human beings into psychiatric care” (van derKolk, 2009) • Are usually not a “single blow” event e.g. rape, natural disaster • Are interpersonal in nature: intentional, prolonged, repeated, severe • Occur in childhood and adolescence and may extend over an individual’s life span • Re-victimization (Terri, 1991; Giller, 1999)

29. What prevalence data tells us? • The majority of adults and children in psychiatric treatment settings have trauma histories • A sizable percentage of people with substance use disorders have traumatic stress symptoms that interfere with achieving or maintaining sobriety • A sizable percentage of adults and children in the prison or juvenile justice system have trauma histories • Victims of trauma are found across all systems of care • Trauma hx often goes undetected (Hodas, 2004, Cusack et al., 2005, Mueser et al., 1998, Lipschitz et al., 1999, NASMHPD, 1998)

30. Juvenile and Criminal Justice • Kentucky, around 30,000 youth are charged with status or public offenses each year (KIDS COUNT Data Book) • Childhood abuse correlated with increased truancy, running away and homelessness (NASMHPD/NTAC, p. 55) • Childhood abuse or neglect increases the likelihood of arrest as a juvenile by 53% and as a young adult by 38%. The likelihood of arrest for a violent crime also increases by 38% (p.49) • PTSD in the juvenile justice population is 8 x’s as high as community samples of similar age peers (Wolpaw & Ford, 2004).

31. Trauma and Criminal Justice • US leads the world in the rate of incarceration of its citizens • KY has the fastest growing prison population in the country • Yet, FBI crime reports indicate KY ranks 40th in violent crime

32. Prevalence Yields Pervasive Consequences

33. Jeremy

34. Jeremy Wade Delle • On January 8, 1991 in Richardson, Tx 16-year old Jeremy Wade Delle--a troubled, beaten, battered and bullied young man entered his english class and spoke • He pulled the trigger of a .357magnum and ended his life in front of his peers • Jeremy’s pain had spoken • Early childhood trauma is never without impact!

35. Consequences of Trauma • Effects are neurological, biological, psychological and social in nature, including: • Changes in brain neurobiology • Social, emotional and cognitive impairment • Adoption of health risks behaviors as coping mechanisms (eating disorders, smoking, substance abuse, self-harm, sexual promiscuity, violence)-- • Severe and persistent behavioral health, social problems, physical health and early death

36. Trauma occurs in layers, with each layer affecting every other layer. Current trauma is one layer. Former traumas in one’s life are more fundamental layers. Underlying one’s own individual trauma history is one’s group identity or identities and the historical trauma with which they are associated. (Bonnie Burstow)

37. Therefore... 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, 2004)

38. The Impact of Trauma

39. Importance of Attachment Emotionally Focused Couple Therapy with Trauma Survivors, Susan Johnson, (2002) Traumatic Experience • Floods us w/ physical fear/helplessness • Colors the world as dangerous/unpredictable • Creates overwhelming emotional chaos • Threatens cohesive sense of self • Assaults self-efficacy and sense of control • Scrambles ability to engage fully in present/adapt to new situations Secure Attachment • Soothes and comforts • Offers safe haven • Promotes affect regulation • Promotes personality integration • Promotes confidence/trust in self and others • Promotes openness to experience, and new learning

40. What’s the point? • When we are uninformed about trauma, we can accidently re-traumatize • Whether or not a given event evokes a trauma response, particularly with children, greatly depends on the response of caregivers • Each service provider a child/adolescent comes into contact with after a trauma event can either hinder, harm or help stimulate healing

41. Comprehensive Impact • Trauma exposure can re-organize a person around the traumatic event • Trauma exposure becomes both the defining and organizing experience that forms the core of a person’s identity • A whole new meaning system develops which informs and guides attempted coping strategies • Trauma changes the whole person not just in particulars

42. Trauma changes your world view

43. Summary • Exposure to trauma is the rule rather than exception • Consider that many individuals bring a lifetime history of trauma (acute and chronic) which impacts the current precipitant situation • This history often results in alteration of brain structure and function

44. Trauma Informed System of Care

46. Trauma Informed Care:Key Principles • Integrate philosophies of care that guide all clinical interventions • Are based on current literature • Are inclusive of the survivor’s perspective • Are informed by research and evidence of effective practice • Recognize that coercive interventions cause traumatization and re-traumatization and are to be avoided (Fallot & Harris, 2002; Ford, 2003; Najavitas, 2003)

47. Trauma Informed Care:Key Features • Recognition of the high rates of PTSD and other psychiatric disorders related to trauma exposure in children and adults with SMI/SED • Early and thoughtful diagnostic evaluation with the focused consideration of trauma in people with complicated, treatment-resistant illness (Fallot & Harris, 2002; Cook et al., 2002; Ford, 2003; Cusack et al.)

48. Trauma Informed Care:Key Features • Valuing the consumer in all aspects of care • Neutral, objective and supportive language • Individually flexible plans and approach • Avoid shaming or humiliation at all times (Fallot & Harris, 2002; Cook et al., 2002; Ford, 2003; Cusack et al.; Jennings, 1998; Prescott, 2000)

49. Trauma Informed Care:Key Features • Awareness/training on re-traumatizing practices • Institutions that are open to outside parties: advocacy and clinical consultants • Training and supervision in assessment and treatment of people with trauma histories (Fallot & Harris, 2002; Cook et al., 2002; Ford, 2003; Cusack et al.; Jennings, 1998; Prescott, 2000)

50. Universal Precautions: A Core Concept Presume that every person in a treatment setting has been exposed to abuse, violence, neglect or other traumatic experiences.