Trauma-Informed Care Implications for law enforcement, social service, and health providers

1. Trauma-Informed CareImplications for law enforcement, social service, and health providers Abbey Stamp, LCSW July 12, 2016

2. A bit about me… • LCSW; clinical practice with high risk youth, adults, and families • 20 years in social service, law enforcement and criminal/family courts • Not a trauma expert, but have expertise in trauma recovery, neurobiology, adult learning, and how trauma impacts practice

3. Who are you? • Where do you work? • Have you had training on trauma previously? • What do you hope to learn?

4. Goal for the day Learn about brains, trauma, and discuss how this information applies to law enforcement and social service practice

5. Agenda • Trauma basics • Human brain development • The impact of trauma on clients • The impact of trauma on service delivery • Trauma Informed practices • Why providers should know about TIC • Application • Questions & Consult time

6. Brain Development • Children: • Brain still forming • Attachment critical • Teens: • Massive brain growth • Risk taking, etc • Adults: • Maturity • Logical reasoning

7. Trauma Basics • Trauma 101 • Single event • Complex marinade over time • Interpersonal violence, especially at the hands of an authority/trusted figure, is particularly damaging • System involved clients often experience both single and complex trauma

8. John Briere, 2006 Trauma is an event that is extremely upsetting and at least temporarily overwhelms internal resources.

9. Traumatic events • Physical assault • Sexual abuse • Emotional or psychological abuse • Neglect/abandonment • Domestic Violence • Gang/street violence • Witnessing abuse/violence • War/Genocide • Accidents • Natural or man-made disasters • Dangerous environment • Witness or experience street violence • Rape • Oppression • Any others?

11. Flippin’ Yer Lid

12. ACE Study • Adverse Childhood Experiences (CDC, 1995) • ACE score includes: • Lack of nurturance and support • Hunger, physical neglect, lack of protection • Divorce in the home • Substance abuse in the home • Mental illness or attempted suicide among household members • Incarceration of household member

13. Cumulative impact • ACE Study: Scores 0-10 • Score of 4 or more: • Twice as likely to smoke • 12 times as likely to have attempted suicide • Twice as likely to be alcoholic • 10 times as likely to have injected street drugs

14. Cumulative impact • ACE score highly correlated with: • Prostitution • Mental Health disorders • Substance abuse • Early criminal behavior • Physical health problems • Early death

15. www.ACEstudy.org

16. “Adolescent” Brain Development: in brief Eat my Shorts

17. How are teen brains different? Adolescence is a time of change and Growth. Generally, teens are trying to figure out: • Independence • Freedom • Differentiating • Identity

18. Implications for humans - Not just little adult brains - Human brain develops until about age 25-27 (starts in tween years) - Over production of grey matter as the brain matures - Connections that are not used undergo pruning. Those that are not used wither away.

19. Prefrontal Cortex Amygdala

20. Neurology shapes behavior With an activated amygdala and frontal lobe under development, the following is normal (and even expected) for young adults: • Risk taking • Challenges with planning and prioritizing • Reward deficiency syndrome • Challenges identifying emotions • Peer influence wins over cognitive reasoning • Just developing the ability to engage in abstract thinking

22. What do people need to become productive, responsible adult brains? • Structure • Limits • Expectations • Love Why? Brain Hero

23. What about folks who have not had a “normal” life? • No structure, limits or expectations • Abuse, neglect • Toxic stress (Fisher) • Adverse Childhood Experiences • Substance abuse (youth and/or parents) • Mental health • Absent/inconsistent parents • System involvement, multiple placements • Trauma (primary & secondary) • -Prelingual vs. lingual

24. ACES and Juvenile Justice

25. Stressed out brains Frontal lobes

26. Eventually teens grow up But they have the same brain

27. Impact of trauma Chronic trauma interferes with neurobiological development and the capacity to integrate sensory, emotional and cognitive information into a cohesive whole.Developmental trauma sets the stage for unfocused responses to subsequent stress(Van der Kolk).

28. Impact of Trauma • Emotional reactions • Feelings—emotions, regulation • Alteration in consciousness--dissociation • Hyper-vigilance • Psychological and cognitive reactions • Concentration, slowed thinking, difficultly with decisions, blame • Crisis is comfortable—homeostasis • Over dependent • Not future oriented • Behavioral and physical reactions • Pain, sleep disturbance, illness, substance abuse • Beliefs: • Changes your sense of self, others, community • World is unsafe • Relational disturbance • Ability to be in relationship

29. Common trauma reactions • Without helpful affect regulation skills, people who are traumatized may have to rely on tension reductions behaviors—external ways to reduce triggered distress (Briere, 2004) • What are some common tension reduction skills?

30. Fear • Accumulated trauma – brain constantly responding to threats • Neurobiological impact • Behavioral outcomes • What does this look like in the folks you encounter in your job?

31. Enter… The System • A person has experienced trauma(s) meets… • Police • Child Welfare • Self Sufficiency • Juvenile Justice • Corrections • Housing • Mental Health system • Healthcare • And on and on and on…

32. If first we must “do no harm”, how do we not make it worse?

33. Trauma Informed Care • “Trauma-Informed Care is a strengths-based framework that is grounded in an understanding of and responsiveness to the impact of trauma that emphasizes physical, psychological, and emotional safety for both providers and survivors to rebuild a sense of control and empowerment.” (Hopper et al, 2010)

34. Trauma Informed Care • “Trauma-informed organizations, programs, and services are based on an understanding of the vulnerabilities or triggers of trauma survivors that traditional service delivery approaches may exacerbate, so that these services and programs can be more supportive and avoid re-traumatization.” (SAMHSA)

35. Core principles of trauma-informed systems of care • Awareness: Everyone understands the impact of trauma • Safety: Ensuring physical and emotional safety. • Trustworthiness: Maximizing trustworthiness, making tasks clear, and maintaining appropriate boundaries. • Choice: Prioritizing consumer choice and control. • Collaboration: Maximizing collaboration and sharing of power with consumers. Integrating care. • Empowerment: Prioritizing consumer empowerment and skill-building. Relationships heal. Recovery is possible.

36. We can’t change people’s childhoods and traumas, but we can increase our sensitivity to how people function due to the impact of earlier experiences.

37. Here’s what we can do • Support trauma recovery (TIC is not trauma recovery or treatment itself) • Enhance engagement • Decrease vicarious trauma/compassion fatigue in staff and officers. • Reduce re-traumatization • Provide “corrective emotional experiences” • Increase trust

38. Trauma informed domains • Trauma informed: • Practice • Administration • Supervision • Systems change • Good for all, but necessary for survivors

39. How might trauma impact behavior? • Difficulty getting motivated and following through with: • Directives • Job training • Education • All or nothing thinking • Seems “turned off”. Lacking emotion. • Impulsive. Reactive. • Does not engage in services • Complains that the system is unfair. Feels they are being targeted. • Interpersonal conflicts with authorities • Irritable, easily agitated, angry

40. Those behaviors are also trauma reduction behaviors • But those behaviors can drive systems and workers nuts! We observe: • Uncooperative • Manipulative • Doesn’t care about rules • Non-compliant • Difficult to engage • What other behaviors might we see that may be resulting from trauma?

41. TIC lens What happened to you? rather than What’s wrong with you? TIC video

42. Trauma isn’t just for clients • Vicarious Trauma • Bearing Witness • Awareness • Self-care

43. TIC: Organizational assessment • Staff Development and Support • Training and Education • Supervision, support and self care • Vicarious trauma prevention • Safe and supportive environment: • Information sharing • Open, respectful communication • Consistency and predictability • Effective delivery of information and services based on trauma awareness

44. TIC: Organizational assessment • Physical environment: • Security • Metal detectors • Lobby • Reception staff • Policies • Adapt and review: • What is truly necessary? • Re-traumatizing? • Assessing and Planning Services • Intake • Goals and plans • Clear, simple goals • Expectations

45. TIC: Organizational assessment • Case Management • Individualize • Empower • Psychoeducation • Directive and involved • Engaged and involved consumers • Unique background • Victimization • Oppression • Etc • Expect multiple tries • Relationships heal • Be consistent yet flexible

46. TIC language • I wonder if… • I notice that… • Because I know it is hard to remember information in times of stress, can you repeat… • Accessing services can sometimes feel traumatizing and scary… • I am getting ready to… • What you can expect is…

47. Applying TIC • Is being knowledgeable about trauma and TIC helpful in your position? If so how? • What are you doing or what can you do to be more trauma informed in your role? • With staff? • With clients? Their families? • What do you need to know more about?

48. Discussion • What are some typical “difficult” behaviors you encounter that may be common trauma responses? • How might you interact with clients to mitigate system impact, reduce trauma responses and increase engagement? • Remember principles of TIC: • Awareness • Safety • Trustworthiness • Choice • Collaboration • Empowerment

49. Questions or follow up? Abbey Stamp, LCSW 503-267-6735 abbey.stamp@gmail.com www.abbeystamp.com