Trauma Informed System of Care:
Changing Our Perspective
Raul Almazar, RN, MA
Senior Consultant
National Center for Trauma Informed Care
Almazar Consulting
What is Trauma?
•
Definition (NASMHPD, 2006)
– 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
Almazar Consulting
The Three E’s in Trauma
Events
Experience
Effects
Events/circumstances
cause trauma.
An individual’s experience
of the event determines
whether it is traumatic.
Effects of trauma include
adverse physical, social,
emotional, or spiritual
consequences.
Slide 4
Traumatic Events:
(1) render victims helpless by overwhelming force;
(2) involve threats to life or bodily integrity, or close
personal encounter with violence and death;
(3) disrupt a sense of control, connection and meaning;
(4) confront human beings with the extremities of
helplessness and terror; and
(5) evoke the responses of catastrophe.
(Judy Herman, Trauma and Recovery, (1992)
Almazar Consulting
Effect of Trauma
The effect of trauma on
an individual can be
conceptualized as a
normal response to an
abnormal situation.
Slide 6
DEFENDING CHILDHOOD
• PROTECT
• HEAL
• THRIVE
REPORT OF THE ATTORNEY GENERAL’S
NATIONAL TASK FORCE ON CHILDREN
EXPOSED TO VIOLENCE
NOV 2012
almazarconsulting.com
Prevalence
• 80% of child fatalities due to abuse and neglect occur
within the first 3 years of life and almost always in the
hands of adults responsible for their care.
• In the US, we lose an average of more than 9 children
and youths ages 5 to 18 to homicide or suicide per day.
• According to the National Survey of Children Exposed to
Violence, an estimated 46 million of the 76 million (61%)
of children currently residing in the US are exposed to
violence, crime and abuse each year.
• 1 in 10 children in this country are polyvictims.
almazarconsulting.com
Effects
• Their fear, anxiety, grief, guilt, shame, and
hopelessness are further compounded by isolation
and a sense of betrayal when no one takes notice or
offers protection, justice, support, or help.
• Exposure to violence in the first years of childhood
deprives children of as much as 10% of their
potential IQ, leaving them vulnerable to serious
emotional, learning and behavior problems by the
time reach school age.
almazarconsulting.com
National Child Abuse Statistics
2011 (Childhelp.org)
• A report of child abuse is made every ten seconds.
• More than four children die every day as a result of
child abuse.
• It is estimated that between 50-60% of child fatalities
due to maltreatment are not recorded as such on
death certificates.
• Approximately 80% of children that die from abuse
are under the age of 4.
• More than 90% of juvenile sexual abuse victims
know their perpetrator in some way.
Almazar Consulting
National Child Abuse stats cont.
• Child abuse occurs at every socioeconomic level, across
ethnic and cultural lines, within all religions and at all levels
of education.
• About 30% of abused and neglected children will later
abuse their own children, continuing the horrible cycle of
abuse.
• In at least one study, about 80% of 21 year olds that were
abused as children met criteria for at least one
psychological disorder.
• The estimated annual cost of child abuse and neglect in the
United States for 2008 is $124 billion.
Almazar Consulting
National Child Abuse stats cont.
• Children who experience child abuse & neglect are about 9
times more likely to become involved in criminal activity.
• Abused children are 25% more likely to experience teen
pregnancy. Abused teens are more likely to engage in sexual
risk taking, putting them at greater risk for STDs.
• As many as two-thirds of the people in treatment for drug
abuse reported being abused or neglected as children.
• More than a third of adolescents with a report of abuse or
neglect will have a substance use disorder before their 18th
birthday, three times as likely as those without a report of
abuse or neglect.
Almazar Consulting
Almazar Consulting
What does the prevalence data mean?
• The majority of adults and children in
mental health treatment settings have trauma
histories as do children and adults served in
a variety of other behavioral and justice
settings
• There appears to be a strong relationship
between victimization and later offending
(Hodas, 2004; Frueh et al, 2005; Mueser et al, 1998; Lipschitz et al,
1999; NASMHPD, 1998)
Almazar Consulting
Therefore ...
We need to presume the clients
we serve have a history of
traumatic stress and exercise
“universal precautions”
(Hodas, 2004)
Almazar Consulting
Prevalence in the General Population
 90% of public mental health clients
have been exposed to trauma.
 In the general population, 61% of men
and 51% of women reported exposure
to at least one lifetime traumatic event,
but majority reporting more than one
traumatic event.
(Kessler, et al, 1995)
Almazar Consulting
Avoidance of 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.
OUR TASK IS TO REPLACE IT WITH A
FEELING OF PRIDE.
Hodas, 2004
[email protected]
Trauma Sensitive
Person
Served
Trauma
Assessment
And
Treatment
Almazar Consulting
Trauma Informed
Care
Trauma Sensitive
Person Served
Trauma Assessment
And Treatment
Universal Precautions
Almazar Consulting
Resiliency
Recovery
Trauma Informed System
NonCoercive
Trauma
Sensitive
Person
Served
NonControlling
Trauma Assessment
and TX
Hope
Collaboration
Partnerships
Almazar Consulting
Healing
ACE Study
Compares adverse childhood
experiences against adult status, on
average, a half century later
Almazar Consulting
ACE Study slides are from:
– Robert F. Anda MD at the Center for Disease Control and
Prevention (CDC)
– September 2003 Presentation by Vincent Felitti MD
“Snowbird Conference” of the Child Trauma Treatment
Network of the Intermountain West
– “The Relationship of Adverse Childhood Experiences to
Adult Medical Disease, Psychiatric Disorders, and Sexual
Behavior: Implications for Healthcare” Book Chapter for
“The Hidden Epidemic: The Impact of Early Life Trauma on
Health and Disease” Lanius & Vermetten, Ed)
Almazar Consulting
Other Critical Trauma Correlates: The Relationship
of Childhood Trauma to Adult Health
• Adverse Childhood Events (ACEs) have serious
health consequences
• Adoption of health risk behaviors as coping
mechanisms
– eating disorders, smoking, substance abuse, self
harm, sexual promiscuity
• Severe medical conditions: heart disease, pulmonary
disease, liver disease, STDs, GYN cancer
• Early Death
(Felitti et al., 1998)
Almazar Consulting
Adverse Childhood Experiences
– Recurrent and severe physical abuse
– Recurrent and severe emotional abuse
– Sexual abuse
• Growing up in household with:
– Alcohol or drug user
– Member being imprisoned
– Mentally ill, chronically depressed, or
institutionalized member
– Separation/Divorce
– Mother being treated violently
– Both biological parents absent
– Emotional or physical abuse
(Fellitti,1998)
Almazar Consulting
ACE Questions:
While you were growing up, during your first 18 years of life:
1. Did a parent or other adult in the household often or very often… Swear at
you, insult you, put you down, or humiliate you? Or Act in a way that made
you afraid that you might be physically hurt?
2. Did a parent or other adult in the household often or very often… Push,
grab, slap, or throw something at you? Or Ever hit you so hard that you had
marks or were injured?
3. Did an adult or person at least 5 years older than you ever… Touch or fondle
you or have you touch their body in a sexual way? Or Attempt or actually
have oral, anal, or vaginal intercourse with you?
4. Did you often or very often feel that … No one in your family loved you or
thought you were important or special? Or Your family didn’t look out for
each other, feel close to each other, or support each other?
Almazar Consulting
ACE Questions:
Con’t
5. Did you often or very often feel that … You didn’t have enough to eat, had
to wear dirty clothes, and had no one to protect you? Or Your parents were
too drunk or high to take care of you or take you to the doctor if you needed
it?
6. Were your parents ever separated or divorced?
7. Was your mother or stepmother: Often or very often pushed, grabbed,
slapped, or had something thrown at her? Or Sometimes, often, or very
often kicked, bitten, hit with a fist, or hit with something hard? Or Ever
repeatedly hit at least a few minutes or threatened with a gun or knife?
8. Did you live with anyone who was a problem drinker or alcoholic or who used
street drugs?
9. Was a household member depressed or mentally ill, or did a household
member attempt suicide?
10. Did a household member go to prison?
Almazar Consulting
The higher the ACE Score,
the greater the likelihood of
:
• Severe and persistent emotional
problems
• Health risk behaviors
• Serious social problems
• Adult disease and disability
• High health and mental health care
costs
• Poor life expectancy
For example:
The following information and slides are from September 2003 Presentation at “Snowbird
Conference” of the Child Trauma Treatment Network of the Intermountain West, by
Vincent J. Felitti, MD. And from Lanius/Vermetten Book Chapter 6/2007
Adverse Childhood Experiences
are Common
Of the 17,000 HMO Members:
• 1 in 4 exposed to 2 categories of ACEs
• 1 in 16 was exposed to 4 categories.
• 22% were sexually abused as children.
• 66% of the women experienced abuse,
violence or family strife in childhood.
Almazar Consulting
The ACE Comprehensive Chart
Adverse Childhood Neurobiological
Long-term Health
Experiences
Impacts and Health and Social
Risks
Problems
The more types of
adverse childhood
experiences…
29
The greater the
neurobiological
impacts and health
risks, and…
The more serious
the lifelong
consequences to
health and wellbeing
Emotional Problems
Almazar Consulting
Childhood Experiences
Underlie
Chronic Depression
% With a Lifetime
History of Depression
Women
80
60
40
20
0
0
2
ACE Score
Almazar Consulting
>=4
Men
% Attempting Suicide
Childhood Experiences
Underlie Suicide
25
4+
20
15
3
10
2
5
0
0
1 ACE Score
Almazar Consulting
• 2/3rd (67%) of all suicide attempts
• 64% of adult suicide attempts
• 80% of child/adolescent suicide attempts
Are Attributable to
Childhood Adverse Experiences
Women are 3 times as likely as men to attempt suicide
Men are 4 times as likely as women to complete
suicide.
ACE Score and Hallucinations
Ever Hallucinated* (%)
12
10
8
6
No
Yes
4
2
0
0
1
2
3
4
ACE Score
5
*Adjusted for
age, sex,
race, and education.
Almazar
Consulting
6
>=7
ACE Score and Impaired Memory
of Childhood
ACE Score
40
Percent With Memory
Impairment (%)
35
30
25
20
15
10
5
0
1
2
3
ACE Score
Almazar Consulting
4
5
Health Risk Behaviors
Almazar Consulting
Adverse Childhood Experiences
and Current Smoking
20
18
16
14
12
10
% 8
6
4
2
0
0
2
4-5
ACE Score
Almazar Consulting
Childhood Experiences and
Adult Alcoholism
% Alcoholic
18
4+
16
14
12
3
2
10
8
6
1
4
2
0
ACE Score
0
Almazar Consulting
% Have Injected
Drugs
ACE Score and Intravenous
Drug Use
4
2
0
0
2
4 or more
ACE Score
Almazar Consulting
N = 8,022
p<0.001
“Male child with an ACE score of 6 has a 4600%
increase in likelihood of later becoming an IV
drug user when compared to a male child with
an ACE score of 0. Might drugs be used for the
relief of profound anguish dating back to
childhood experiences? Might it be the best
coping device that an individual can find?”
(Felitti, 1998)
Almazar Consulting
Is drug abuse selfdestructive or is it a
desperate attempt at
self-healing, albeit while
accepting a significant
future risk?”
(Felitti,
1998)
Almazar Consulting
• Basic cause of addiction is
experience-dependent, not
substance-dependent
• Significant implications for
medical practice and treatment
programs
Almazar Consulting
Serious Social Problems
Almazar Consulting
Childhood Experiences
Underlie Rape
35
4+
% Reporting Rape
30
25
20
3
2
15
1
10
5
0
ACE Score
0
Almazar Consulting
ACEs Underlie Domestic Violence
Women with ACE
Score of 4+ are
500% more likely to
become victims of
domestic violence.
Both men and
women are more
likely to become
perpetrators of
domestic violence
Almazar Consulting
Almazar Consulting
Adjusted Odds Ratio
Adverse Childhood Experiences and
Likelihood of > 50 Sexual Partners
4
3
2
1
0
0
ACE Score
Almazar Consulting
% have Unintended PG, or AB
ACE Score and Unintended
Pregnancy or Elective Abortion
80
60
40
20
0
0
2
4 or more
ACE Score
Unintended Pregnancy
Almazar Consulting
Elective Abortion
Adjusted Odds Ratio
Adverse Childhood Experiences
and
History of STD
3
2.5
2
1.5
1
0.5
0
0
3
ACE Score
Almazar Consulting
Sexual Abuse of Male Children and Their
Likelihood of Impregnating a Teenage Girl
1.8x
1.3x
1.4x
1.0 ref
Not
abused
16-18yrs 11-15 yrs <=10 yrs
Age when first abused
Almazar Consulting
Frequency of Being Pushed, Grabbed, Slapped, Shoved or Had
Something Thrown at Oneself or One’s Mother as a Girl and the
Likelihood of Ever Having a Teen Pregnancy
Pink =self
Green =mother
Never
Once,
Sometimes
TwiceAlmazar Consulting
Often
Very
often
ACE Score and Indicators of
Impaired Worker Performance
25
Prevalence of Impaired
Performance (%)
ACE Score
20
0
1
2
3
4 or more
15
10
5
0
Absenteeism (>2
days/month
Serious Financial
Poblems
Almazar Consulting
Serious Job
Problems
“What happened to you?”
instead of
“What’s wrong with you?”
Almazar Consulting
From “What’s Wrong?” To,
“What’s Happened?”
• What is your
diagnosis?
• What are your
symptoms?
• How can I best help
or treat you?
• What is your story?
How did you end up
here?
• How have you coped
and adapted?
• How can we work
together to figure
out what helps?
Trauma Symptoms =
Tension Reducing Behaviors
“How do I understand this
person?”
rather than
“How do I understand this problem
or symptom?”
[email protected]
 All behavior has meaning
 Symptoms are ADAPTATIONS
 Comfort vs. Control
 We build on success not deficits
Almazar Consulting
Resilience Questionnaire
• What’s Your Resilience Score?
• This questionnaire was developed by the early childhood service
providers, pediatricians, psychologists, and health advocates of
Southern Kennebec Healthy Start, Augusta, Maine, in 2006, and
updated in February 2013. Two psychologists in the group, Mark
Rains and Kate McClinn, came up with the 14 statements with
editing suggestions by the other members of the group. The scoring
system was modeled after the ACE Study questions. The content of
the questions was based on a number of research studies from the
literature over the past 40 years including that of Emmy Werner
and others. Its purpose is limited to parenting education. It was not
developed for research.
• Please circle the most accurate answer under each
statement:
• 1. I believe that my mother loved me when I was little.
• 2. I believe that my father loved me when I was little.
• 3. When I was little, other people helped my mother and
father take care of me and they seemed to love me.
• 4. I’ve heard that when I was an infant someone in my
family enjoyed playing with me, and I enjoyed it, too.
• 5. When I was a child, there were relatives in my family
who made me feel better if I was sad or worried.
• 6. When I was a child, neighbors or my friends’
parents seemed to like me.
• 7. When I was a child, teachers, coaches, youth
leaders or ministers were there to help me.
• 8. Someone in my family cared about how I was
doing in school.
• 9. My family, neighbors and friends talked often
about making our lives better.
• 10. We had rules in our house and were
expected to keep them.
• 11. When I felt really bad, I could almost always
find someone I trusted to talk to.
• 12. As a youth, people noticed that I was
capable and could get things done.
• 13. I was independent and a go-getter.
• 14. I believed that life is what you make it.
• How many of these 14 protective factors did I
have as a child and youth? (How many of the 14
were circled “Definitely True” or “Probably
True”?)
• Faith, hope, sense of meaning
COMMUNITY,
CULTURE,
SPIRITUALITY
KEY SYSTEMS
FOR
RESILIENCE Nourishment
Protection
Wholeness
Growth
CAPABILITY
• Engagement with effective orgs –
schools, work, pro-social groups
• Network of supports/services &
opportunity to help others
• Cultures providing positive standards,
expectations, rituals, relationships &
supports
ATTACHMENT
&
BELONGING
• Bonds with parents and/or
caregivers
• Positive relationships with
competent and nurturing adult
• Friends or romantic partners wh
provide a sense of security &
belonging
• Intellectual & employable skills
• Self regulation – self control,
executive function, flexible
thinking
• Ability to direct & control
attention, emotion, behavior
• Positive self view, efficacy
EXAMPLES OF PROGRAM & POLICY ACTIONS
• Parent Trust for Washington Children has incorporated the ACE questions into their
work with addicted parents facing court action (DV, termination of parental rights)
resulting in: 1) improved outcomes in parenting classes and 2) reduced relapse
among parents with 4 or more ACEs.
• Safe Harbor Crisis Nursery in the Tri-Cities has incorporated ACEs and trauma into its
day-to-day strategies and case management resulting in improved outcomes for
families.
• Children of Incarcerated Parents; the Legislature has mandated the executive branch to
engage in an initiative to address the needs of children of incarcerated parents. The
initiative and its processes are framed to address the likelihood that these children
have more than this one ACE.
• With the help of the Mental Health Transformation Grant and the Office of the
Superintendent of Public Instruction (OSPI), Spokane is exploring the
creation/implementation of trauma sensitive practices in public schools.
• OSPI introduced the Compassionate Schools initiative, which supports local school
districts in reducing the non-academic barriers to schools success that are created by
trauma (2008). (http://www.k12.wa.us/CompassionateSchools/default.aspx)
Punishment vs. Compassion
Killarney Secondary School 2010 – 2013
Lincoln High School 2009 – 2011
Vandalism, false fire alarms, locker breakins drug deals common
Kids kicked out of other schools, last
chance; gangs controlled building.
• Discipline by Enforcement of
Punishment, Obedience
• Zero Tolerance and no skill
building to manage stress
• Totalitarian atmosphere, Fear,
vigilance and mistrust
• Regard unruly behavior as willful
disobedience
• Students feel like potential
criminals
• What’s wrong with this kid?
• Suspensions and absenteeism
down 30%
• Discipline by Respect,
Understanding, Compassion
• Fair Consequences and skill
building to manage stress
• Atmosphere of Safety and
Trusting Relationships
• Regard unruly behavior as a
manifestation of trauma
• Students feel understood and
treated fairly
• What is happening with this kid?
• Suspensions and absenteeism
down 87%
Neurodevelopment of Childhood
Bruce D. Perry, M.D., Ph.D.
www.ChildTrauma.org
How Trauma Affects the Brain
• Experiences Build Brain
Architecture
• Serve & Return Interaction
Shapes Brain Circuitry
• Toxic Stress Derails Healthy
Development
Slide 67
The Brain Matters
• The human brain is the organ responsible for
everything we do. It allows us to love, laugh,
walk, talk, create or hate.
• The brain - one hundred billion nerve cells in a
complex net of continuous activity -allows us
our humanity.
• For each of us, our brain’s functioning is a
reflection of our experiences.
The biological unit of survival
for human beings is the clan.
Evolutionary pressure which resulted
in our species was applied to the
clan, not the individual.
We are unavoidably inter-dependent
upon each other.
The compartmentalization of
Western life
•
•
•
•
•
•
•
Separate by age
Separate by wealth
Separate by work
Separate in education, by profession
Separate by transportation
Separate by generation
Separate by ethnicity, religion, race
Decrease in Size of Households
Privacy and Isolation
Developmental Stages
• Emotional Regulation for infants
• Maternal dyad
• Repetitive, patterned interaction to
hardwire self-regulation
• Exploration of individual self, tentative
independence, tolerating manageable
separations
• Independence
Neocortex
Limbic
Diencephalon
Brainstem
• Abstract Thought
• Concrete Thought
•
•
•
•
Affiliation
Attachment
Sexual Behavior
Emotional Reactivity
•
•
•
•
Motor regulation
Affect regulation
Hunger/satiety
Sleep
•
•
•
•
Blood pressure
Body temperature
Heart rate
Arousal states
Peers, Teachers
Community
Family and Friends
Caregiver
Mother
Rauch Brain scans
Bottom-Up Responses
Prefrontal
Cortex
Frontal lobes shut
down or decrease
activity to ensure
instinctive
responding
Amygdala
Becomes “irritable”,
Increasingly sensitive to triggers
Thalamus
Ability to
perceive new
information
decreases
Triggering
Stimulus
(Restak, 1988)
Lateral Ventricles Measures in an 11 Year Old
Maltreated Male with Chronic PTSD, Compared with
a Healthy, Non-Maltreated Matched Control
(De Bellis et al., 1999)
Between Stimulus and Response
Cortex
Hippocampus
Sensory Thalamus
Very Fast
Slower
Amygdala
S Stimulus
Response
(LeDoux, 1996)
Between Stimulus and Response
Social
Environmental
Intervention
Cortex
Hippocampus
Sensory Thalamus
S Stimulus
Very Fast
Neuroregulatory
Intervention
Psychotherapy
Psychopharmacology
Slower
Amygdala
In between stimulus and response,
there is a response, in that space lies
our power to choose our response, in
our response lies our growth and
freedom. Viktor Frankl
Response
(LeDoux, 1996)
Serum Cortisol
• Cortisol Response to a Cognitive Stress Challenge in PTSD
Related to Childhood Abuse
Finding: There were elevated levels of cortisol in both the
time period in anticipation of challenge (from time 60 to 0)
and during the cognitive challenge (time 0–20). PTSD patients
and controls showed similar increases in cortisol relative to
their own baseline in response to the cognitive
challenge.(Bremner, Vythilingam, et al 2002)
Implications for Children
• EXPERIENCE CAN CHANGE THE
MATURE BRAIN - BUT EXPERIENCE
DURING THE CRITICAL PERIODS OF
EARLY CHILDHOOD ORGANIZES
BRAIN SYSTEMS!
– From Bruce Perry, Trauma and Brain
Development
St. Aemilian-Lakeside
Video about a trauma-informed program for children with
emotional and behavioral problems
St. Aemilian-Lakeside Trauma-Informed Care
Slide 81
The Four R’s
A trauma-informed program, organization, or system:
Realizes
• Realizes widespread impact of trauma and
understands potential paths for recovery
Recognizes
Responds
Resists
• Recognizes signs and symptoms of trauma in clients,
families, staff, and others involved with the system
• Responds by fully integrating knowledge about trauma
into policies, procedures, and practices
• Seeks to actively Resist re-traumatization.
Slide 82
Gender Differences in PTSD
Raul Almazar
Almazar Consulting
[email protected]
Olff, Langeland et al
Gender Differences in PTSD
2007, Psychological Bulletin
Male
Female
Rate of Exposure
60.7%
51.2%
Rate of Developing PTSD
8.1%
20.4%
Types of Trauma
More susceptible to
negative effects of
childhood neglect
Prior Traumatization
No difference
•Greater exposure to
traumas that have high
rates of PTSD
•More than 1/3 of
women experienced
intimate partner violence
within the past 12
months
•More susceptible to
negative effects of sexual
abuse
• More exposure at a
younger age
Male
Cognitive Appraisal
•Higher levels of
perceived control
•Lower reliance on
blaming others
Female
•More likely to report
threat and loss
appraisals
•More likely to appraise
events as stressful
•Higher perceived
distress loss of personal
control and lack of
available coping
strategies
•Pick up on threat
signals more readily
Male
Female
Coping
• Instrumental Mastery
• Fight or Flight
•Tend and Befriend
• Freezing
• Passive avoidance
Perry’s theory
Psychological and
Biological Response
Are more sensitized to
physiological
heyperarousal systems
– conduct disorder,
ADD, antisocial
- Higher SNS activity
•More sensitized to
dissociated systems –
anxiety, physical
complaints, withdrawal
• HPA dysregulation
- Oxytocin
- Estrogen
Endogenous Opioids
Male
Health Outcomes
More aggressive
behaviors
Female
• Higher PTSD rates
• More anxiety,
depressive
disorders,
somatization,
alcohol and drug
use
How Our Bodies Respond to a Real
or Perceived Threat or a Trigger
• Hypothalamus-Pituitary-Adrenal Axis
(HPA) Brings body into balance
– Sympathetic Nervous System
• Fight, Flight or Freeze
– Heart rate
– Sweat response
– Energy increase
Our Body’s Chemical Response
• Cortisol
– Regulation of the Adrenalines
– Increase of energy
• Adrenalines
– Fight or flight
– Sharpens our focus and stimulates memory
– Increases blood pressure and heart rate
– Shunts blood away from systems that are not
needed in danger response to the brain and
muscles
Our Body’s Chemical
Response 2
• Our natural Opioids
– Prevents experiencing the pain
– prevents memory consolidation
• Oxytocin
– Inhibits memory consolidation
• Vasopressin
– Prevents dehydration
Biochemical changes during and
after the traumatic event
• Adrenaline - levels are chronically
increased resulting in constant
hyperstress and inability to distinguish
danger signals
– Inability to sleep, flashbacks, trouble with
concentrating
– Shuts off the brain
Biochemical changes during and
after the traumatic event 2
• Cortisol- Chronically low or high levels results in reduced immune functioning,
impaired regulation of the adrenalines,
and damage to passages in the brain
responsible for memory
– While high, cortisol, thins stomach lining
and bones, impairs the immune system,
decreases blood flow to the intestines.
Gender Differences in the
Trauma Response
• Females - tend to dissociate and
paradoxically, trauma bond
• Males - fight or flee, exert power and
control
• However - Both sexes will experience
power and control and difficulties with
species preservative behavior if the
traumas and/or triggers continue too
long
Gender Differences in Trauma
Response 2
• Females - Tend and Befriend
– Shelley Taylor, UCLA
• The role of our hormones
– Estrogen amplified the effects of
oxytocin
– Androgens diminish the effects of
oxytocin
Creating Positive Cultures
Trauma Informed Workforce
Development
Raul Almazar, RN, MA
Senior Consultant
SAMHSA’s National Center for Trauma Informed Care
Some Stressors:










Fiscal and funding cuts
Downsizing/organizational changes/ mergers
DIfferent payor systems
Regulatory changes
Role changes
Reimbursement changes
Do more with less
Practice changes
New metrics
Natural organizational events
almazarconsulting.com
Impact on the Individual
 Loss of meaning and purpose
 Decreased creativity
 Inability to innovate
 Absenteeism
 Retreating into the familiar
 Distracted, unfocused
 Physical health effects
almazarconsulting.com
Organizational Impact
Turnover
 Workers Compensation
 Loss of market advantage
 Decreased productivity
 Creation of additional positions to supplement lagging
productivity
 Increased training costs
 With an unhappy workforce - more susceptible to
litigation
 Sustained stress response imbedded in the
organizational culture
almazarconsulting.com
2009 GALLUP POLL
EMPLOYEE ENGAGEMENT INDEX
• 33% - Engaged in their jobs
• 49% - Are not Engaged
• 18% - Actively Disengaged
almazarconsulting.com
Biological
Trauma lives in the body. The body
has ways to indicate to us that a
threat cue is perceived.
Stress/Trauma Lives in the Body
• A chronic overreaction to stress overloads the
brain with powerful hormones that are
intended only for short-term duty in
emergency situations.
• Serum cortisol levels
• Chronic hyperarousal – nervous system does
an amazing job of preparing the individual to
deal with the stress but:
almazarconsulting.com
 Growth, reproduction and immune system all
go on hold
 Leads to sexual dysfunction
 Increases chances of getting sick
 Often manifests as skin ailments
 Increases permeability of the blood brain
barrier
 Dr. Robert Sapolsky: “Why Zebras Don’t Get
Ulcers” – study on salmon
More on changes as the result of
too much stress
• Chronically high cortisol levels
– Insulin resistance, poor sleep patterns –
reinforces bad eating habits – no energy to
exercise
– Can produce cytokines, a protein that
promotes inflammation – linked to heart
disease, depression, arthritis and fibromyalgia
– Impacts regulation adrenalines – implications
for hippocampus and addiction
SAMHSA’s Six Key Principles of a TraumaInformed Approach
• Safety
• Trustworthiness and Transparency
• Peer Support
• Collaboration and Mutuality
• Empowerment, Voice, and Choice
• Cultural, Historical, and Gender Issues
Slide 105
Principle 1: Safety
Throughout the organization,
staff and the people they
serve, whether children or
adults, feel physically and
psychologically safe.
Video: Leah Harris
Slide 106
Who Defines Safety?
For people
who use
services:
“Safety” generally
means maximizing
control over their own
lives
For providers:
“Safety” generally
means maximizing
control over the
service environment
and minimizing risk
Slide 107
Principles of TIC:
SAFETY
Raul Almazar, RN, MA
SAMHSA National Center for Trauma Informed Care
National Association of State Mental Health Program
Directors
Contact info:
[email protected]
Safety
Throughout the organization: Staff and the people they serve (children
and adults)
 Feel
physically safe
 Feel psychologically safe
 Physical setting is safe
 Interpersonal interactions promote a sense of
safety
 Safety as defined by the people served
almazarconsulting.com
Four Types of Safety
Adapted from Sandra Bloom’s Sanctuary
Model:
Physical Safety
Psychological Safety
Moral Safety
Social Safety
almazarconsulting.com
Physical Safety
 Sense of being safe, living in a physically safe
space
 Physical/Biological Safety
 Good health practices
 Occupational security and sound financial
management (Core TIA Principle: Trustworthiness and
Transparency)
Psychological Safety
 Sense of mastery over one’s life
Living in a world that has some predictability
Ability to express ones’ creativity
Self-efficacy
Presence of structure and organization within
which one can try new ideas
 Ability to make sense of what has happened/is
happening
Moral Safety
 Having a sense of meaning and purpose
 Sense of hope and empowerment (Core TIA Principle:
and Choice)
 Firm belief in Recovery, Recovery as a moral
Peer Support)
Empowerment, Voice
imperative ( Core TIA Principle:
 Sense of integrity, courage and justice
 Providing and receiving the most effective
treatment
 Attending to power differentials to promote health and
Principle: Collaboration and Mutuality
 Practicing democratic principles
healing (Core TIA
Social Safety
 Sense of feeling secure, cared for,
trusted
 Ability to express oneself
 Ability to be safe with other people
 Acceptance of differences and diversity
( Core TIA Principle:
Cultural/Historical/Gender sensitivity)
Psychosocial Safety Climate
The shared belief held by workers that their
psychological safety and well-being is protected
and supported by senior management.
Defined as an organization or team level
construct that refers to policies, practices and
procedures that are upheld by managers and
leaders for the protection of worker psychological
health and safety
(Dollard and Bakker, 2010)
almazarconsulting.com
ORGANIZATIONAL Climate vs. Culture
• Organizational Climate – shared perceptions of policies,
practices and procedures present within an organization.
(Reichers & Schneider, 1990)
Observable manifestations of the organization
• Organizational Culture - underlying core values of an
organization that are inherent, rather than observable.
( Bochner, 2003)
almazarconsulting.com
Security vs. Safety
Security surrounds, but safety enfolds. Perhaps the
lingering differences between the words can be
found in their differing etymologies.
Safe comes from Latin salvus, “uninjured, healthy. It’s
related to salus, “good health.”
Secure comes from Latin securus, “without care,” from
se, “free from,” and cura, “care.”
almazarconsulting.com
To my mind, security suggests freedom from
worries that derive from knowing that certain
external safeguards are in place and that I can
rely on them to protect me and my property.
Safety is a richer word that includes an inner
certainty that all is well. In a sense, security is
external, while safety is internal.
From Maeve Maddox, Writing Tips, Academic Generalist
almazarconsulting.com
Risk Management
Risk management is the identification,
assessment, and prioritization of risks
followed by coordinated and economical
application of resources to minimize, monitor,
and control the probability and/ or impact of
unfortunate events or to maximize realization
of opportunities. (ISO31000)
almazarconsulting.com
Establishing the Context
To establish the context means to define the external
and internal parameters that organizations must
consider when they manage risk.
ISO 31000 expects you to consider your organization’s
context when you define the scope of its risk
management program, when you formulate its risk
management policy, and when you establish its risk
criteria.
almazarconsulting.com
External Context
An organization’s external context includes all of the
external environmental parameters and factors that influence
how it manages risk and tries to achieve its objectives.
It includes its external stakeholders, its local, national, and
international environment, as well as key drivers and trends
that influence its objectives.
It includes stakeholder values, perceptions, and relationships, as
well as its social, cultural, political, legal, regulatory, financial,
technological, economic, natural, and competitive
environment.
almazarconsulting.com
Internal Context
An organization’s internal context includes
all of the internal environmental parameters and
factors that influence how it manages risk and tries
to achieve its objectives.
It includes its internal stakeholders, its approach to
governance, its contractual relationships, and
its capabilities, culture, and standards.
almazarconsulting.com
Managing Risk
ISO 31000:2009 gives a list on how to deal with risk:
 Avoiding the risk by deciding not to start or continue with the
activity that gives rise to the risk
 Accepting or increasing the risk in order to pursue an
opportunity
 Removing the risk source
 Changing the likelihood
 Changing the consequences
 Sharing the risk with another party or parties (including
contracts and risk financing)
 Retaining the risk by informed decision
almazarconsulting.com
Examples
•
•
•
•
•
Failure Mode Effects Analysis (FMEA)
Suicide
Accidental Death
Personal Safety Device
Strategic Plan
almazarconsulting.com
Principles of TIC:
Peer Perspectives on Safety
Malcolm Aquinas, MAT
SAMHSA National Center for Trauma Informed Care
National Association of State Mental Health Program
Directors
Contact info:
Malcolm.M.Aquinas[email protected]
“Creating safety is not about getting it right
all the time; it’s about how consistently and
forthrightly you handle situations with a client
when circumstances provoke feelings of being
vulnerable or unsafe. Honest and
compassionate communication that
conveys a sense of handling the
situation together generates safety.”
-SAMHSA TIP 57
Safety
Generalize safety concerns from the Peer Perspective
across two broad areas
•Responsiveness
– Applies to behavioral health services and systems
•Competence
– Applies to providers of services within those systems
Six Safety Considerations
1. Environment
2. Meetings
3. Predictability
4. Reliability
5. Dependability
6. Transparency
Environment
• Allow us to choose our own seat
• Provide easy access to exits
• Communicate clearly and supportively that we have
free egress from rooms
• Express empathetic support without strong emotions
• Remember that our senses (sight, sound, smell,
taste, and touch) are vigilantly searching for possible
threats
Meetings
•
•
•
•
What is the content under discussion?
In what context is it being presented?
How much information is being presented?
In what amount of time is the information
being presented?
• How many people are presenting the
information?
• What is potentially triggering?
• In what ways was the individual supported to
prepare for the material?
Predictability
•
•
•
•
Who interacts with us?
How do they present themselves?
What schedules exist?
How confidently can we move around in
our environment?
Reliability
• Do you follow through on things you commit
to do?
• Do you accomplish tasks in the agreed upon
timeframe?
• If you cannot complete an agreed upon task,
either at all or in the timeframe agreed to, do
you communicate that information to us with
the reasons why?
Dependability
• Is there someone we can go to for
support?
• Are they available when we need them?
• Are they trustworthy?
Transparency
• Are we included in the decision-making
process?
• Is information related to our treatment and
care communicated in a timely manner, by
people we trust, in a way we can understand
it?
• Are we provided opportunities to ask
questions in a retaliation-free environment?
• Do providers understand how critical this is
for us if trust is to be established?
Je ne sais quoi
•
•
•
•
•
•
•
Openness – Be inviting and welcoming
Honesty – Speak truthfully
Compassion – Demonstrate active kindness
Empathy – Validate personally
Genuineness – Be present
Transparency – Pull back the curtain
Vulnerability – Show that this matters
“You’ve seen my descent.
Now watch my rising.”
~Rumi
Always Remember:
1. It’s what happened to us, not what’s wrong with us;
and
2. We may be stuck, but we are not broken.
Reducing Risk, Creating Safety
Together
Leah Harris, MA
SAMHSA National Center for Trauma Informed Care
National Association of State Mental Health Program
Directors
Contact info:
[email protected]
Twitter: @leahida
Redefining Risk
• Issues of safety and risk come up particularly around suicide
and self-harm, which are often trauma responses.
• Suicide risk increases with ACE score (Felitti et al, 1998).
• Trauma informed approaches emphasize the primacy of
healing in mutual relationships.
• Traditional forms of assessment and liability fears interfere
with these relationships.
• Dynamics of power and control take away from traumainformed care and approaches to suicide prevention and
intervention.
Responses to my suicidality
• As a trauma survivor with a history of intense suicidal feelings
and self-harm, I was never given the space to make sense of
these feelings in traditional settings.
Responses:
• Police response – carted away in handcuffs
• Being punished with loss of privileges for self-harming on the
ward
• Threatened with interventions I didn’t want
• No one asked “what happened to you?”
• Consequently, I learned to hide my suicidal thoughts and
feelings and self-harming behaviors.
Safety as a Euphemism for Control
• Safety is one of our deepest human needs.
• In many human service settings, people who are suicidal can
experience unwanted, traumatic, and humiliating
interventions, all in the name of “safety.”
• We need to understand that in this context, safety is a
euphemism for “control.”
• Shery Mead talks about “fear-based” vs. “hope-based”
responses to suicide.
• Many people in human service fields have been trained not to
acknowledge this fear to themselves or the other person, and
move directly into “control mode.”
Liability Drives the System
• “If we don’t rethink the notion of
risk, the liability issue will continue to
drive what we do.” - Shery Mead
Safety Contracts: Not Safe
• Safety contracts are usually developed to address the
provider or support person’s fear and agency fears of
liability
• Safety contracts are inherently coercive and not in line with
trauma informed care
• “Signing a safety contract rather than talking about the
painful feelings is just another way of generating
powerlessness.” Shery Mead
• Signing a no-suicide contract should not be used in a
coercive way, or as a condition for the person to keep
receiving support.
Ways of Approaching Shared Risk:
Crisis and Safety Planning
• In a mutual support relationship, responses to crisis are
negotiated together in advance of a crisis happening.
• Crisis planning: one approach is to have a plan for how to
address risk and dangerousness in advance.
• When you ask the question, you can figure out a response
together pro-actively.
• This approach is trauma-informed and respects a person’s
wishes for dignity and respect.
• Replace the safety contract with a safety plan.
• Developing a plan for next steps for self-care, support, etc. is
important, but it should be a collaborative process that the
person experiencing the suicidal feelings has said
would be helpful
Authenticity
• Traditional treatment relationships discourage the support
person’s authentic expression of their own feelings.
• Trauma-informed relationships are a two way street.
• Trauma-informed practitioners learn to recognize within
themselves the desire to control someone’s behavior out of
fear.
• In such a scenario, it would be completely appropriate for a
supporter to tell someone who is suicidal, “I have to be
honest - hearing you talk about this feels scary for me. But I
am willing to try to sit with these feelings as we talk.”
Authenticity
• Though suicidal feelings are common, talking about them is
taboo.
• In the traditional provider-patient relationship, sharing about
these personal experiences is discouraged.
• In a trauma-informed relationship, the peer practitioner
discloses own past or current struggles with suicidal thoughts,
when applicable. “I’ve felt that way, too.”
• Peer practitioners also share coping skills (strategies) they
have found useful to manage their own suicidal thoughts or
feelings.
• Trauma informed approaches facilitate learning and growth
for both the support person and person in
distress/crisis.
Emotional CPR to create safety
• Emotional CPR (eCPR) is a public health education program
that promotes a trauma-informed approach to supporting
people in crisis and distress.
• The most important thing we can do as eCPR practitioners is
to develop an authentic, heart-to-heart connection with a
person experiencing suicidal thoughts or feeling unsafe in any
way.
• When a relationship begins with trying to check off items on
an assessment/screening form, it is much harder to establish
that authentic connection.
Emotional CPR to create safety
• When practicing eCPR, we drop the traditional assessment
agenda (e.g. How long have you been suicidal? Do you have a
plan?) and seek to build trust and understanding.
• We may ask questions of our own, but they are curious and
open-hearted, such as:
• What has happened to cause you to feel this way?
• How can I support you right now?
• What do you need right now?
• Has anything or anyone helped you in the past when you’ve
felt this way?
It’s about Mutual Relationships
• Even when people don’t have shared experiences, building
mutually empathic relationships is the only way that people
can build a “new, shared” story. - Shery Mead
• “Creating a new, shared story involves a willingness to take
risks in relationship even when we are uncomfortable with
the situation.” Shery Mead
• Learning from crisis: we can share what we have learned in
the wake of a crisis, and use those learning to create a new
crisis plan that will help prevent future crises and offer us
more opportunities for healing and growth.
Resources
• Defining Outcomes for Crisis Response by Shery
Mead and Eric Kuno: http://bit.ly/1orvn4e
• Crisis and Connection by Shery Mead and David
Hilton http://bit.ly/1jtXcRE
• Peer Support: What Makes it Unique? by Shery
Mead and Cheryl MacNeil: http://bit.ly/REt2F7
• Intentional Peer Support:
www.intentionalpeersupport.org/
• Emotional CPR: www.emotional-cpr.org
Discussion
Do staff feel safe in
your organization?
Why or why not?
What changes
could be made
to address
safety
concerns?
Do the people served
feel safe?
How do you know?
Slide 151
Principle 2: Trustworthiness and
Transparency
Organizational operations and decisions are conducted
with transparency and the goal of building and
maintaining trust among clients, family members, staff,
and others involved with the organization.
Video: Pat Risser
Slide 152
Examples of Trustworthiness
• Making sure people really
understand their options
• Being authentic
• Directly addressing limits to
confidentiality
Slide 153
Discussion
How can we promote trust
throughout the organization?
Do the people served trust
staff? How do you know?
What changes could be made
to address trust concerns?
Slide 154
Principle 3: Peer Support
Peer support and mutual self-help
are key vehicles for establishing
safety and hope, building trust,
enhancing collaboration, serving as
models of recovery and healing,
and maximizing a sense of
empowerment.
Video: Cicely Spencer
Slide 155
Examples of Peer Support
Peer support = A flexible approach to building
mutual, healing relationships among equals,
based on core values and principles:
Voluntary
Nonjudgmental
Slide 156
Respectful
Reciprocal
Empathetic
Discussion
Does your
organization offer
access to peer
support for the
people who use your
services? If so, how?
What barriers are
there to
implementing peer
support in your
organization?
Does your
organization offer
peer support for
staff?
Slide 157
Principle 4: Collaboration and Mutuality
Partnering and leveling of power differences
between staff and clients and among
organizational staff from direct care to
administrators; demonstrates that healing
happens in relationships, and in the
meaningful sharing of power and decisionmaking.
Everyone has a role to play; one does not have
to be a therapist to be therapeutic.
Slide 158
Examples of Collaboration
“There are no static roles of ‘helper’ and ‘helpee’—reciprocity is the key
to building natural community connections.”—Shery Mead
Hospital abolished special parking privileges and opened the “Doctor’s
Only” lounge to others
Models of self-directed recovery where professionals facilitate but do
not direct
Direct care staff and residents in a forensic facility are involved in every
task force and committee and are recognized for their valuable input
Slide 159
Discussion
Can you think of examples from
your agency of true partnership
between staff and people served?
What about partnership between
top-level administrators and line
staff?
Can you think of changes that
would significantly decrease the
power differentials in your
agency?
Slide 160
Principle 5: Empowerment, Voice, and
Choice
Individuals’ strengths and experiences are recognized
and built upon; the experience of having a voice and
choice is validated and new skills developed.
The organization fosters a belief in resilience.
Clients are supported in developing self-advocacy skill
and self-empowerment
Video: GAINS Center Interview Video
Video: William Kellibrew
Slide 161
Examples
Asking at intake:
“What do you
bring to the
community?”
Treatment
activities designed
and led by hospital
residents
Slide 162
Murals on walls
painted by staff
and residents
Turning
“problems” into
strengths
Discussion Question
How can you use your clients’
strengths?
Slide 163
Discussion
• Can you think of examples from your work
setting of empowerment, voice and choice
for people served?
• What about for staff?
• Can you think of policies or practices that
do the opposite—that take voice, choice,
and decision-making away? Could any of
these things be changed?
Slide 164
Principle 6: Cultural, Historical, and Gender
Issues
The organization actively moves
past cultural stereotypes and biases,
offers gender-responsive services,
leverages the healing value of
traditional cultural connections, and
recognizes and addresses historical
trauma.
Video: Iden Campbell
Slide 165
Examples: A Place of Healing
Hawaii women’s prison builds a traumainformed culture based on the Hawaiian
concept of pu`uhonua, a place of refuge,
asylum, peace, and safety.
Video: TEDx Talk by Warden Mark Patterson
Slide 166
Traumatic Reminders
• Loss of Control
• Power Differential
• Lack of Predictability
almazarconsulting.com
I've learned that people will forget
what you said, people will forget what
you did, but people will never forget
how you made them feel.
~ Maya Angelou
[email protected]
847.613.8361
[email protected]
202.236.7747
SAMHSA’s National Center for
Trauma Informed Care
Almazar Consulting
Download

Pre-Conference Presentation