Preparing the Adult Mental Health Workforce to Succeed in a Transformed System of Care

1. Preparing the Adult Mental Health Workforce to Succeed in a Transformed System of Care Module XIII Understanding Trauma Informed Care Huckshorn, Stromberg, LeBel, 2004 2009 1

2. Objectives Upon completion of this module, participants will be able to: Discuss the impact of traumatic experiences in the lives of the people we serve Be familiar with the prevalence of trauma among persons served in different types service settings Describe how our emerging knowledge about trauma indicates a need for the prevention of the use of coercive practices wherever possible Identify the characteristics of trauma-informed versus non-trauma-informed settings 2

3. When Anne Heche Disclosed �I told my mother at about the seventh year of therapy that I had been abused sexually by my father, and she hung up the phone on me� 3

4. What is Trauma? Trauma is: A personal, often extreme, event Usually a horrific experience Impacts people profoundly Redefines a person�s life 4

5. Traumatic Life Events that Can Result in Mental Health Problems: Are interpersonal in nature: intentional, prolonged, repeated Includes sexual abuse, physical abuse, severe neglect, emotional abuse Also includes, witnessing violence, repeated abandonment, sudden and traumatic loss Can occur in childhood, adolescence or at any time in an adult�s lifetime 5

6. Trauma Informed Health Care Staff Demonstrate: An appreciation for the very high prevalence of traumatic life 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, and how these effects can translate into a person�s day-to-day behavior Commitment to proving care that is collaborative, supportive and skill-based (Jennings, 2004) 6 High prevalence means a high number�.In other words, it is safe to assume that most people we serve have experienced serious trauma� Early childhood trauma actually has a physiological impact on brain development�therefore what is needed is care that is stabilizing and addresses this physiologic dysregulation High prevalence means a high number�.In other words, it is safe to assume that most people we serve have experienced serious trauma� Early childhood trauma actually has a physiological impact on brain development�therefore what is needed is care that is stabilizing and addresses this physiologic dysregulation

7. How is Trauma Defined? NASMHPD (2004): The experience of violence and victimization including sexual abuse, physical abuse, severe neglect, loss, domestic violence, and/or the witnessing of violence, terrorism or disasters DSM IV-TR (APA, 2000): Person�s response involves intense fear, horror, and helplessness Extreme stress that overwhelms the person�s capacity to cope 7 FYI to Presenter: NASMHPD is the National Association of State Mental Health Program Directors. The photo here is of Joan Gillece, a NASMHPD faculty member who provides training across the country on trauma-informed careFYI to Presenter: NASMHPD is the National Association of State Mental Health Program Directors. The photo here is of Joan Gillece, a NASMHPD faculty member who provides training across the country on trauma-informed care

8. Trauma that is Disabling Can Impact: Feelings � people are emotionally overwhelmed, fearful, anxious, and helpless Thinking � people can�t think clearly when stressed, or manage their anxiety or distress Functioning � a person�s capacity to function in every-day-life is impaired 8 Read slide. Then mention to the audience that sometimes staff can misinterpret a consumer�s behavior which can escalate a problem. Note the importance of not making negative or accusatory assumptions about the reasons for the behaviors of the people we serve.Read slide. Then mention to the audience that sometimes staff can misinterpret a consumer�s behavior which can escalate a problem. Note the importance of not making negative or accusatory assumptions about the reasons for the behaviors of the people we serve.

9. If you think that trauma is only sexual or physical abuse 9 Mention to the audience that trauma can also include verbal, psychological, or emotional abuse (such as threatening a person; making hostile and demeaning comments that are intended to erode a person�s self-worth; etc.)Mention to the audience that trauma can also include verbal, psychological, or emotional abuse (such as threatening a person; making hostile and demeaning comments that are intended to erode a person�s self-worth; etc.)

10. Trauma Informed Care is Based on an Understanding that: Trauma represents a profound loss of control Trauma is not just a memory. It may have happened in the past, but it impacts the present and effects a consumer�s health & development, and the ability to learn & function Care must be collaborative, supportive, skill-based, and focused on helping people reclaim control (Jennings, 2004) 10 Read slide. Then explain that, when working from a trauma paradigm, behaviors are not pathologized, but rather are seen as coping mechanisms developed as a response to previous trauma. Read slide. Then explain that, when working from a trauma paradigm, behaviors are not pathologized, but rather are seen as coping mechanisms developed as a response to previous trauma.

11. Prevalence of Trauma in Adults with Serious Mental Illness (SMI) 97% of homeless women with SMI: (Goodman et al, 1997) 90% of public mental health clients (Mueser et al, in press; Mueser et al, 1998) 81% of adults diagnosed bipolar disorder and 90% of those with dissociative identity disorder (Herman et al, 1989; Ross et al, 1990) 29-43% of people with SMI have PTSD (CMHS/HRANE, 1995; Jennings & Ralph, 1997) 11 Read slide with added thoughts 97% of homeless women with serious mental illness have experienced severe physical & sexual abuse 87% experience abuse both in childhood and adulthood (Goodman et al, 1997) 90% of public mental health clients have been exposed to trauma and multiple experiences of trauma (Mueser et al, in press; Mueser et al, 1998) 81% of adults diagnosed with bi-polar disorder and 90% of those with dissociative identity disorder were sexually or physically abused as children Herman et al, 1989; Ross et al, 1990) 29-43% of people with serious mental illness have post traumatic stress disorder (PTSD) Rosenberg and his colleagues from Dartmouth University who have done a good deal of research on people in the public mental health system found that 90% of these individuals have been exposed to trauma. Goodman, in a separate study, found that 51-98% were exposed. Meusar and Felitti identified that most have had multiple experiences of various types of traumatic stress. Homeless women are particularly vulnerable to rape Read slide with added thoughts 97% of homeless women with serious mental illness have experienced severe physical & sexual abuse 87% experience abuse both in childhood and adulthood (Goodman et al, 1997) 90% of public mental health clients have been exposed to trauma and multiple experiences of trauma (Mueser et al, in press; Mueser et al, 1998) 81% of adults diagnosed with bi-polar disorder and 90% of those with dissociative identity disorder were sexually or physically abused as children Herman et al, 1989; Ross et al, 1990) 29-43% of people with serious mental illness have post traumatic stress disorder (PTSD) Rosenberg and his colleagues from Dartmouth University who have done a good deal of research on people in the public mental health system found that 90% of these individuals have been exposed to trauma. Goodman, in a separate study, found that 51-98% were exposed. Meusar and Felitti identified that most have had multiple experiences of various types of traumatic stress. Homeless women are particularly vulnerable to rape

12. Prevalence of Traumain Children & Adolescentswith Mental Health Problems Of 187 adolescents, 42% reportedly had PTSD (Kotlek, Wilkes, & Atkinson, 1998) Of 100 adolescent in an inpatient setting, 93% had trauma histories and 32% had PTSD (Lipschitz et al, 1999) Among child/adolescent long-term care service-users (162) it was found that 100% had documented trauma histories (Massachusetts DMH, 2007, in press) 12 Even though this training is for staff who work with adults, they, of course, were once children�. Several studies have found high prevalence rates of trauma histories among children and youth being served in the mental health system. For example: 1. A Canadian study of 187 adolescents reported that 42% had post traumatic stress disorder (PTSD) (Kotlek, Wilkes, & Atkinson, 1998) 2. An American study of 100 adolescents in inpatient settings found that 93% had trauma histories and 32% had PTSD (Lipschitz et al, 1999) 3. A study of one state system�s child/adolescent long-term care service-users (162) found that 100% had documented trauma histories Also note that, in addition to persons with serious mental health issues, people with Intellectual & Developmental Disabilities also have high rates of trauma history: The risk of abuse increases by 78% due to exposure to the �disabilities service system� alone (Sobsey & Doe, 1991) There appears to be increased vulnerability to abuse in institutional settings (White, Holland, Marsland & Oakes, 2003) Sexual abuse incidents are 4 times as common in institutional settings as in community (Blatt & Brown, 1986) (*Citations from Charlton et al (2004) Even though this training is for staff who work with adults, they, of course, were once children�. Several studies have found high prevalence rates of trauma histories among children and youth being served in the mental health system. For example: 1. A Canadian study of 187 adolescents reported that 42% had post traumatic stress disorder (PTSD) (Kotlek, Wilkes, & Atkinson, 1998) 2. An American study of 100 adolescents in inpatient settings found that 93% had trauma histories and 32% had PTSD (Lipschitz et al, 1999) 3. A study of one state system�s child/adolescent long-term care service-users (162) found that 100% had documented trauma histories Also note that, in addition to persons with serious mental health issues, people with Intellectual & Developmental Disabilities also have high rates of trauma history: The risk of abuse increases by 78% due to exposure to the �disabilities service system� alone (Sobsey & Doe, 1991) There appears to be increased vulnerability to abuse in institutional settings (White, Holland, Marsland & Oakes, 2003) Sexual abuse incidents are 4 times as common in institutional settings as in community (Blatt & Brown, 1986) (*Citations from Charlton et al (2004)

13. Prevalence of TraumaAmong Persons in Substance Abuse (SA) Treatment Up to 2/3 of men and women in SA treatment report childhood abuse & neglect (SAMSHA CSAT, 2000) Study of male veterans in SA inpatient unit 77% exposed to severe childhood trauma 58% history of lifetime PTSD (Triffleman et al, 1995) 50% of women in SA treatment have history of rape or incest (Gov. Comm. on Sexual and Domestic Violence, Comm. of MA, 2006) 13 Read slide. Note, too, that high rates of trauma are also found among persons in correctional settings. For example: --At Framingham Women�s Prison in Massachusetts, 90% of inmates receiving mental health services or substance abuse services have trauma histories. (Governor�s Task Force, Comm. of MA., 2005) --At the Correctional Institute for Women in Rhode Island, the following prevalence rates are reported: 40% - Childhood sexual abuse, 55% - Childhood physical abuse, 53% - Adult rape, 63% - Adult physical assault, 34% - Lifetime PTSD. (Zlotnick, 1997; Zlotnick, Najavits et al, 2003) Read slide. Note, too, that high rates of trauma are also found among persons in correctional settings. For example: --At Framingham Women�s Prison in Massachusetts, 90% of inmates receiving mental health services or substance abuse services have trauma histories. (Governor�s Task Force, Comm. of MA., 2005) --At the Correctional Institute for Women in Rhode Island, the following prevalence rates are reported: 40% - Childhood sexual abuse, 55% - Childhood physical abuse, 53% - Adult rape, 63% - Adult physical assault, 34% - Lifetime PTSD. (Zlotnick, 1997; Zlotnick, Najavits et al, 2003)

14. Prevalence of TraumaIn Incarcerated Youth 93% males in a juvenile justice facility reported a trauma history compared to females (84%), although more females in the study met criteria for PTSD (18% of females, 11% of males) (Abram et al., 2004) 70% - 92% of incarcerated girls reported sexual, physical, or severe emotional abuse in childhood (DOC, 1998, Chesney & Sheldon, 1997) 14 Again, even though this training is aimed at persons serving adults, this data is being presented on youth in the juvenile justice system because youth in the �deep end� of that system run the risk of of ending up in institutional settings (both corrections and mental health) as adults. In terms of the prevalence of Post Traumatic Stress Disorder in youth, prevalence data varies widely. It is however, the best defined and most clearly understood trauma diagnosis, among people with serious mental illness � 3% to 50% in JJ settings and up to 8 times higher than community samples of same-age peers (Arroyo, 2001; Garland et al, 2001; Teplin et al, 2002;. Saigh et al, 1999, Saltzman et al, 2001). Even without a formal diagnosis of PTSD, however, the prevalence of trauma within this population is extremely high. Again, even though this training is aimed at persons serving adults, this data is being presented on youth in the juvenile justice system because youth in the �deep end� of that system run the risk of of ending up in institutional settings (both corrections and mental health) as adults. In terms of the prevalence of Post Traumatic Stress Disorder in youth, prevalence data varies widely. It is however, the best defined and most clearly understood trauma diagnosis, among people with serious mental illness � 3% to 50% in JJ settings and up to 8 times higher than community samples of same-age peers (Arroyo, 2001; Garland et al, 2001; Teplin et al, 2002;. Saigh et al, 1999, Saltzman et al, 2001). Even without a formal diagnosis of PTSD, however, the prevalence of trauma within this population is extremely high.

15. Well Known & Not-So-Well-Known People Aren�t Immune From Trauma Desperate Housewives� star Teri Hatcher revealed she was sexually abused by her uncle after he was arrested for molesting another girl Many well-known and not-well-known people have experienced trauma 15

16. Shame & Humiliation:Recognizing Survival Strategies Garbarino�s �Lost Boys� research identifies: Vulnerability to feeling �shamed� Importance of allowing child to �save face� Juvenile vigilantism, survival strategy Gang affiliate offers new, better family Lack of future orientation, sense of meaninglessness � tendency to take risks (Garbarino, 1999; Hodas, 2004) 16 --James Garbarino, Ph.D. is Co-Director of the Family Life Development Center, and a Professor of Human Development at Cornell University. In his work �Lost Boys: Why our Sons Turn Violent and How we Can Save Them,� he looks at a variety of factors, from birth through adolescence that contribute to the problem of violence. --As the 1st bullet notes, youth who have been abused/neglected/abandoned can feel exquisite vulnerability to being demeaned and have a need to ward off vulnerability and replace it with feelings of pride� --What may be viewed by society as �bad behavior,� such as joining a gang, may actually be viewed by the child as a survival strategy (i.e. that the gang gives the child attention or protection or food that he may not be getting at home) --Understanding these issues is important when working with persons in prison populations and juvenile justice.--James Garbarino, Ph.D. is Co-Director of the Family Life Development Center, and a Professor of Human Development at Cornell University. In his work �Lost Boys: Why our Sons Turn Violent and How we Can Save Them,� he looks at a variety of factors, from birth through adolescence that contribute to the problem of violence. --As the 1st bullet notes, youth who have been abused/neglected/abandoned can feel exquisite vulnerability to being demeaned and have a need to ward off vulnerability and replace it with feelings of pride� --What may be viewed by society as �bad behavior,� such as joining a gang, may actually be viewed by the child as a survival strategy (i.e. that the gang gives the child attention or protection or food that he may not be getting at home) --Understanding these issues is important when working with persons in prison populations and juvenile justice.

17. Prevalence of TraumaCorrectional Settings Some researchers describe a pathway in which: Exposure to violence, and Pervasive feelings of not being safe� �develop into a state of chronic threat requiring the youth/adult to use physical aggression in order to manage these stressors (Schwab-Stone et al, 1995) 17

18. What About People Who Aren�t in Health Care or Human Service Settings? Over 50% of U.S. women and 60% of men report experiencing at least 1 traumatic event at some point in their lives (Koenen, 2005; Kessler et al., 1995) More than 80% of those diagnosed with PTSD will suffer from other psychiatric disorders (Solomon & Davidson, 1997) 18 With regard to the first bullet, note that despite the high rates of trauma exposure, only a minority (10% of women & 5% of men) report developing posttraumatic stress disorder, the most prominent psychiatric disorder associated with traumatic events. With regard to the first bullet, note that despite the high rates of trauma exposure, only a minority (10% of women & 5% of men) report developing posttraumatic stress disorder, the most prominent psychiatric disorder associated with traumatic events.

19. Author and Actress In my own case, growing up in an alcoholic home, I came to accept chaos as a normal state of affairs rather than the exception I wound up sabotaging my first marriage simply because the calm left me unsettled and nervous; I had to create chaos where none existed because that's all I was familiar with  - Suzanne Somers, actress & author 19

20. Other Current Trauma ResearchChildhood Trauma-Adult Behaviors Adverse Childhood Experiences (ACE) have serious health consequences People appear to adopt risky health behaviors as coping mechanisms in adulthood, including: Eating disorders, smoking, substance abuse, self harm, sexual promiscuity These behaviors result in: Severe medical conditions: Heart disease, pulmonary disease, liver disease, sexually transmitted diseases, cervical cancer, early death (Felitti et al, 1998) 20 --The ACE Study is an ongoing collaboration between the Centers for Disease Control and Prevention and Kaiser Permanente. �Led by Co-principal Investigators Robert F. Anda, MD, MS, and Vincent J. Felitti, MD, the ACE Study is perhaps the largest scientific research study of its kind, analyzing the relationship between multiple categories of childhood trauma (ACEs), and health and behavioral outcomes later in life. --The study has shown that childhood trauma (such as abuse, neglect, and exposure to domestic violence) is a risk factor for a variety of behavioral and somatic health difficulties and it has increased our understanding of the pervasive impact that traumatic experiences can have on an individual.

21. What Does All of This Mean? Most of the people served in: Psychiatric treatment settings have trauma histories Prison or juvenile justice systems have trauma histories People who are not in care settings may also experience trauma � that means staff, too (Hodas, 2004, Frueh et al, 2005; Mueser et al, 1998; Lipschitz et al., 1999; NASMHPD, 1998) 21 --Traumatic exposure is epidemic among adults and children in the mental health system. --Many clinicians in the US see PTSD as the only trauma-related diagnosis. Increasingly, however, we are appreciating that a range of other disorders can be directly related to trauma exposure; or individuals might suffer from such co-occurring conditions as substance abuse, affective illness, personality disorders and psychotic disorders. --Traumatic exposure is epidemic among adults and children in the mental health system. --Many clinicians in the US see PTSD as the only trauma-related diagnosis. Increasingly, however, we are appreciating that a range of other disorders can be directly related to trauma exposure; or individuals might suffer from such co-occurring conditions as substance abuse, affective illness, personality disorders and psychotic disorders.

22. What if You Don�t Know if Someone Has a Trauma History? Remember the prevalence research Take a �universal precautions� approach � assume everyone we serve has a history of trauma (Hodas, 2004) 22

23. Universal Precautions Creating a trauma informed setting means using individualized, strength-based interventions to avoid conflict and violence, to ensure safety, to meet needs, and to minimize any traumatic event that could hurt clients or staff (NETI, 2005) And remember� �Kindness is a language that the deaf can hear and the blind can see� Mark Twain 23 These kinds of �precautions� are aimed at preventing illness or injury before they take place. Like hand washing techniques to avoid passing on colds or using condoms for �safe sex� Additionally, being trauma-informed entails treating people with respect, valuing their input, and focusing upon their strengths. These kinds of �precautions� are aimed at preventing illness or injury before they take place. Like hand washing techniques to avoid passing on colds or using condoms for �safe sex� Additionally, being trauma-informed entails treating people with respect, valuing their input, and focusing upon their strengths.

24. What Does a Trauma Informed Care System Look Like? �If you can, help others; if you cannot do that, at least do not harm them� - Dalai Lama 24

25. Interventions are based on current literature Care is informed by research and evidence of effective practice Providers recognize that coercive interventions can cause traumatization and re-traumatization and are to be avoided 25 The principles of trauma-informed care are fully consistent with person-center, recovery oriented care It is important to mitigate the effects of trauma by avoiding practices that are coercive and controlling [including the use of seclusion and restraint] which can cause a person to be re-traumatized.The principles of trauma-informed care are fully consistent with person-center, recovery oriented care It is important to mitigate the effects of trauma by avoiding practices that are coercive and controlling [including the use of seclusion and restraint] which can cause a person to be re-traumatized.

26. How Would Trauma be Addressed? Trauma Informed Non Trauma Informed Recognition of high prevalence of trauma Life history is appreciated/recorded Assess for traumatic histories & symptoms Recognition of setting/culture and practices that are re-traumatizing Lack of education on trauma prevalence & �universal� precautions Person seen without family/social history Cursory or no Trauma Assessment �Tradition of Toughness� valued as best care approach 26

27. A Trauma Informed Service Recognizes: �Any intervention that recreates aspects of previous traumatic experiences or that uses power to punish is harmful to the individual involved.� (NASMHPD, 1998) 27

28. How Would the Service Feel? Trauma Informed Non Trauma Informed Power/Control is minimized - constant attention to practices Language Counselors, staff Caregivers/supporters � Collaboration Address training needs of staff to improve knowledge & sensitivity Keys, security uniforms, gruff staff demeanor, authoritative tone of voice Techs, guards Rule enforcers � Compliance �Patient-blaming� as fallback position without training 28 Non-trauma-informed environments present a controlling, paternalistic model in which others �know what�s best� Laura Prescott, a trauma survivor and advocate, discussed the difference between a trauma informed vs trauma un-informed system with the following example: A woman is in an institutional environment that feels unsafe. Large men � loud voices � keys displayed � doors locked. This is a woman who had been locked in her room and repeatedly abused by her father when she was younger. It is late evening, the time when she was typically abused by her father. A staff member comes into the unit and yells to another staff person. The woman feels triggered � she re-experiences the abuse in her body, and she feels unsafe. To manage - she finds a paper clip and starts digging into her skin, in the way that many trauma survivors will self-injure to stop dissociation. But then three men jump on her to restrain her � and put her in four point restraints�.which makes her even more terrified. Alternatively, consider that this same woman is in an environment where people know her and work with her as an individual. Staff do not yell at one another or the consumers. The woman gets anxious because it is bedtime (an internal trigger because it is the time of day when she would be abused) � and she starts to pace. But then the nurse approaches her to talk to her in a calm and supportive manner. It is a very different picture. Non-trauma-informed environments present a controlling, paternalistic model in which others �know what�s best� Laura Prescott, a trauma survivor and advocate, discussed the difference between a trauma informed vs trauma un-informed system with the following example: A woman is in an institutional environment that feels unsafe. Large men � loud voices � keys displayed � doors locked. This is a woman who had been locked in her room and repeatedly abused by her father when she was younger. It is late evening, the time when she was typically abused by her father. A staff member comes into the unit and yells to another staff person. The woman feels triggered � she re-experiences the abuse in her body, and she feels unsafe. To manage - she finds a paper clip and starts digging into her skin, in the way that many trauma survivors will self-injure to stop dissociation. But then three men jump on her to restrain her � and put her in four point restraints�.which makes her even more terrified. Alternatively, consider that this same woman is in an environment where people know her and work with her as an individual. Staff do not yell at one another or the consumers. The woman gets anxious because it is bedtime (an internal trigger because it is the time of day when she would be abused) � and she starts to pace. But then the nurse approaches her to talk to her in a calm and supportive manner. It is a very different picture.

29. How would you feel? 29

30. How Would People be Treated? Trauma Informed Non Trauma Informed Understand function of behavior (rage, repetition-compulsion, self-injury) Objective, neutral language Consumer is center of their treatment Transparent systems open to outside parties Behavior seen as intentionally provocative & volitional Labeling language: manipulative, needy, gamey, �attention-seeking� Lack of self-directed care Closed system � advocates discouraged 30 Note with regard to Self-injury: Sandy Bloom couches it as a �valiant attempt� to cope. Many trauma survivors will self-injure (cutting, etc.)� -- as a strategy for managing flashbacks, terror, and numbing; --to help the survivor regain control; --to make the person them feel strong instead of powerless; --to stop the person from dissociating; --to convert emotional pain to physical pain It is also very important to recognize and address (not deny or ignore) the consumer�s own definition and experience of trauma. Note with regard to Self-injury: Sandy Bloom couches it as a �valiant attempt� to cope. Many trauma survivors will self-injure (cutting, etc.)� -- as a strategy for managing flashbacks, terror, and numbing; --to help the survivor regain control; --to make the person them feel strong instead of powerless; --to stop the person from dissociating; --to convert emotional pain to physical pain It is also very important to recognize and address (not deny or ignore) the consumer�s own definition and experience of trauma.

31. How would you want to be heard? 31

32. What Would You Hear? Trauma Informed Non Trauma Informed  Asking people how they prefer to be addressed Quietly making rounds and informing people of schedule �Let�s talk and find you something to do� �May I help you?� Calling people by first name without permission or last name w/out title Yelling �lunch� or �medications� �If I have to tell you one more time�.� �Step away from the desk� 32 The key here is to focus on the positive, and to treat people in a dignified and respectful manner. Consider the following example (Taken from Difficult Conversations: Work shop for Non-Clinicians to Become Trauma-Informed, Denis, E. Elliot, Psy.D, DeniseEll@aol.com. The Consortium Rene Anderson, Project Director.) Conversation A: Woman: �I�m not sure if I am in the right place. You�re the third person I�ve been to in this building. I�m supposed to see a Dr. Edwards. Staff response: Name? Woman: Sally Bellings Staff: Here, you have to fill out this form. Conversation B: Woman�same statement as above. Staff: �I�m sorry you had such a hard time finding us. Dr. Edwards does work here. If you want to give me your name, I�ll make sure you are in his appointment book. Woman: Sally Bennings Staff: Here you are for 2:30. He is running a little late but you should be able t see him by 2:45. Sorry for the delay. In the mean time, could you please fill out this form?The key here is to focus on the positive, and to treat people in a dignified and respectful manner. Consider the following example (Taken from Difficult Conversations: Work shop for Non-Clinicians to Become Trauma-Informed, Denis, E. Elliot, Psy.D, DeniseEll@aol.com. The Consortium Rene Anderson, Project Director.) Conversation A: Woman: �I�m not sure if I am in the right place. You�re the third person I�ve been to in this building. I�m supposed to see a Dr. Edwards. Staff response: Name? Woman: Sally Bellings Staff: Here, you have to fill out this form. Conversation B: Woman�same statement as above. Staff: �I�m sorry you had such a hard time finding us. Dr. Edwards does work here. If you want to give me your name, I�ll make sure you are in his appointment book. Woman: Sally Bennings Staff: Here you are for 2:30. He is running a little late but you should be able t see him by 2:45. Sorry for the delay. In the mean time, could you please fill out this form?

33. What Would You See? Trauma Informed Non Trauma Informed Modified nursing station without barrier � welcoming and open Checks to check-in with the person � eye contact Saying hello and goodbye at beginning and end of shift Large barrier around nursing station � �us/them� Checks to simply locate � focus on task, not person Coming in and leaving without acknowledgement 33

34.  The Importance of Carefully Assessing Trauma A more sensitive review of someone�s trauma history should be done respectfully and shortly after admission in order to: Identify past or current trauma, violence, abuse experiences Learn how trauma is expressed when the person is under duress Incorporate this information into an individualized, person-specific care plan (Cook et al, 2002; Fallot & Harris, 2002; Maine BDS, 2000) 34

35. Common Trauma Symptoms People Struggle With Dissociation Flashbacks Nightmares Hyper-vigilance Terror Anxiety Negative auditory hallucinations Numbness, Depression Substance abuse Self-injury Eating problems Sexual promiscuity Poor judgment and continued cycle of victimization 35 People with traumatic exposure may have difficulty functioning within a level of optimal arousal and demonstrate symptoms of hypo or hyper arousal: --Hypo arousal being demonstrated as numbing, dissociation, flattened affect, withdrawal, disconnection. --Some of the hyper arousal symptoms demonstrate a continued emergency state of fight or flight including: flashbacks, terror, hyper vigilance. --A person with a trauma history may also experience a feeling of invisibility. --Note that there can be cultural contexts, too, to the ways in which people experience or process traumatic events.People with traumatic exposure may have difficulty functioning within a level of optimal arousal and demonstrate symptoms of hypo or hyper arousal: --Hypo arousal being demonstrated as numbing, dissociation, flattened affect, withdrawal, disconnection. --Some of the hyper arousal symptoms demonstrate a continued emergency state of fight or flight including: flashbacks, terror, hyper vigilance. --A person with a trauma history may also experience a feeling of invisibility. --Note that there can be cultural contexts, too, to the ways in which people experience or process traumatic events.

36. Trauma Assessment Components Type- Sexual, physical, emotional, neglect, witnessed domestic violence, exposure to disaster, combat exposure, other Age- When the abuse occurred is important in terms of the impact on the person�s development Who- Was abuser a stranger? Family member? (Carmen et al, 1996) 36 Read slide. Then, at end of slide note: Someone who had a relatively stable life and was then raped at 22 will have had a before and after life changing event. But this is different from someone sexually abused by a parent consistently from an early age who may suffer from more a severe fragmentation of the self and the inability to become close to or trust another person.Read slide. Then, at end of slide note: Someone who had a relatively stable life and was then raped at 22 will have had a before and after life changing event. But this is different from someone sexually abused by a parent consistently from an early age who may suffer from more a severe fragmentation of the self and the inability to become close to or trust another person.

37. Trauma Assessment: Key Principles Focus on �what happened to you� instead of �what is wrong with you� (Bloom, 2002) Begin to develop a therapeutic relationship (trust, respect, caring) during this process Create a crisis prevention/safety plan to use in the hospital/care setting to learn and practice new self-calming skills 37 Read slide. Note that the key is to have a context of the human experience rather than a pathology framework. Read slide. Note that the key is to have a context of the human experience rather than a pathology framework.

38. Trauma Assessment: Key Principles Information from the assessment and �positive responses� to current abuse questions must be incorporated into treatment and discharge plans or the assessment has no value Also, if previously disclosed, what happened? Ask if the person has ever told anyone, at all� 38

39. Re-Victimization When a victim reaches out for help or reports the abuse, she/he is often re-victimized by a society who doesn�t want to hear what they need to hear. The re-victimization leaves long lasting emotional scars and �cuts deep wounds� in the victim�s psyche - Coral Anika Theill 39

40. In Summary Most of the people in our care have been traumatized Stress can worsen trauma symptoms Difficult behaviors are sometimes learned survival strategies Try to understand the consumer�s history and how to support efforts to teach self-calming 40

41. In Summary Practices that take away control and choice can be traumatizing Watch for trauma �uninformed� practice and try to prevent, avoid or eliminate it Keep asking � is what I am doing respectful and trauma-informed? 41

42. Elie Wiesel,Two lessons in my life There are no sufficient literary, psychological, or historical answers to human tragedy, only moral ones. Just as despair can come to one another only from other human beings, hope, too, can be given to one only by other human beings. - Author & Holocaust Survivor 42

43. Optional Video Behind Closed Doors Behind Closed Doors is an excellent short documentary�20 minutes� that was developed by the Maryland Disability Law Center. It is the very moving story of 4 young women struggling to recover from traumatic experiences as children and then later in the psychiatric system. The instructor may wish to note to the audience that the video may cause a viewer to feel sad or have feelings that are uncomfortable and to advise viewers that they are free to step out of the room for a moment, if they need to. By the way, the majority of these women are doing quite well now. Have a dialogue after the film to discuss ways that our service systems may unintentionally trigger persons with trauma histories and what we might do to make our approach to care more supportive. This video can be downloaded for free from the following site: http://www.nasmhpd.org/WFvideos.cfm It may take a little while to download, so the trainer should do so in advance.Behind Closed Doors is an excellent short documentary�20 minutes� that was developed by the Maryland Disability Law Center. It is the very moving story of 4 young women struggling to recover from traumatic experiences as children and then later in the psychiatric system. The instructor may wish to note to the audience that the video may cause a viewer to feel sad or have feelings that are uncomfortable and to advise viewers that they are free to step out of the room for a moment, if they need to. By the way, the majority of these women are doing quite well now. Have a dialogue after the film to discuss ways that our service systems may unintentionally trigger persons with trauma histories and what we might do to make our approach to care more supportive. This video can be downloaded for free from the following site: http://www.nasmhpd.org/WFvideos.cfm It may take a little while to download, so the trainer should do so in advance.