A Trauma-Informed Understanding of Suicidality
Elizabeth Hudson, LCSW
Consultant to WI Dept. of Health Services
Employed by University of Wisconsin - Madison
Psychological Trauma - What is it?
Extreme stress (e.g., threat to life, bodily integrity or sanity) that
overwhelms a person’s ability to cope.
The individual’s subjective
event is traumatic.
experience determines whether or not an
feelings of vulnerability,
helplessness and fear.
Traumatic events result in a
interfere with relationships and
fundamental beliefs about oneself, others and one’s place in the
Traumatic events often
world.
Posttraumatic Stress Disorder = re-experiencing, avoidance/numbing
& hyperarousal
)
Psychological Trauma - Examples
• Violence in the home, personal relationships, workplace, school,
systems/institutions, or community
• Maltreatment or abuse: emotional, verbal, physical, sexual, or
spiritual
• Exploitation: sexual, financial or psychological
• Abrupt change in health, employment, living situation over
which people have no control
• Neglect and deprivation
• War or armed conflict
• Natural or human-caused disaster
Trauma-related Statistics
56% of the general population reported at least one
traumatic event
(Kessler,1995)
90% of mental health clients have been exposed to a
traumatic event and most have multiple exposures
(Muesar, 1998)
83% of females and 32% of males with
developmental disabilities have experienced sexual
assault. (Hard, 1986) Of those who were assaulted, 50% had
been assaulted 10 or more times
(Sobsey and Doe, 1991)
97% of homeless women with mental illness experienced
severe physical and/or sexual abuse (Goodman, Dutton et al., 1997)
Trauma has been associated with suiciderelated thoughts or behaviors in populations
such as:
– Vietnam veterans (Fontana and Rosenheck, 1995),
– American Indians (Robin et al., 1997),
– psychiatric inpatients (Sfoggia et al., 2008),
– people with substance disorders (Roy et al., 2007),
– medical students (Jeon et al., 2009),
– college students (Bryant and Range, 1997),
– adolescents (Lipschitz et al., 1999),
– military men and women (Hoge et al., 2004).
Adverse Childhood Experience (ACE) Study
http://www.acestudy.org/
http://www.cdc.gov/nccdphp/ACE/
‘ACE’
Abuse
Household with:
• Psychological (by
parents)
• Substance abuse
• Physical (by parents)
• Mental illness
• Sexual (anyone)
• Separation/divorce
• Physical neglect
• Domestic violence
• Emotional neglect
• Imprisoned household
member
Childhood Experiences
Underlie Suicide
25
4+
% Attempting Suicide
20
15
3
10
2
5
1
0
0
ACE Score
Complex Trauma / Complex PTSD / Developmental
Trauma Disorder
Result of traumatic experiences that are
interpersonal, intentional, prolonged and repeated
Symptoms of Complex Trauma
Re-experiencing
Avoidance/ Numbing
Arousal
PLUS
• Emotional difficulties: managing feelings; chronic anxiety;
empathizing; low frustration tolerance; expressing needs, thoughts,
concerns using words
• Cognitive difficulties: cognitive biases; understanding what is being
said; doing things in logical sequence; seeing ‘gray’; working with time;
multiple ideas simultaneously; maintaining focus
• Social difficulties: attending to or accurately assessing social cues;
connecting with others; seeking attention in appropriate ways;
appreciating how behavior impacts others
• Handling transition and change: impulsive; adapting to change;
handling unpredictability, ambiguity, uncertainty & novelty
• Interference with developmental momentum: social withdrawal;
decreased range of affect; regression in development; decrease in play
Impact on Worldview
Typical Development vs. Developmental Trauma
• Nurturing & stable
attachments with adults
• Belief in a predictable &
benevolent world/
generally good things will
happen to me
• Feeling of positive selfworth /others will see my
strengths
• Optimism about the future
• Feeling that I can have a
positive impact on the
world
• Basic mistrust of
adults/inability to depend
on others
• Belief that the world is an
unsafe place/bad things
will happen & they are
usually my fault
• Assumption that others
will not like me
• Fear & pessimism about
future
• Feelings of hopelessness
& lack of control
Mediating or Exacerbating Factors
Person
• Age / developmental stage
• Past experiences and coping skills
Environment
• Presence of sensitive & supportive ‘other’
• Safe community
• Access to supportive resources
• Culture and cultural beliefs
Event
• Severity & chronicity
• Interpersonal vs. act of nature
• Intentional vs. accidental
Suicidality and Surviving Trauma:
Shared Elements
People often…
–
–
–
–
–
–
–
–
aren’t asked
don’t tell
feel they have secret and experience shame
experience failure and sense of unworthiness
feel isolated and alone
feel helpless and hopeless
feel detached
have impaired judgment and self-regulation
(Hodas, 2008)
Providers Respond …
• Hospitalization
•
Psychotropic medication
•
Outpatient treatment
Trauma-Informed Care
What it is:
a philosophical shift
What it is not:
an intervention to address PTSD
----------------------Moving from, ‘What’s wrong with you’
to
‘What’s happened to you?’
Shneidman’s Two Questions
Where do you hurt?
How can I help?
(McCord, Marian University, September, 2011)
Trauma-Informed Care – What is it?
Incorporate knowledge about trauma –
prevalence, impact, and recovery – in all aspects
of service delivery
Place priority on:
1.
2.
3.
4.
5.
6.
meaningful consumer engagement
physical and emotional safety
choice
collaboration / sharing power
empowerment and skill building (1-5, Fallot & Harris)
healing relationships
Increase caregiver capacity
Guiding Values of
Trauma-Informed Care
Healing Happens in
Relationship
TIC within Suicide Prevention: Beliefs
• People often feel out of control, but don’t talk
about it
• Core considerations: avoid power struggles and
the use of shame & humiliation
• People need…
–
–
–
–
trusting relationships
information for self-awareness and goals
to develop more effective coping skills
support in regaining hope
(Hodas, 2008)
TIC within Suicide Prevention: Practices
•
•
•
•
•
•
•
Address any continuing trauma or danger
Actively engage and build relationship
Be welcoming and non-judgmental
Build on strengths
Gather trauma and treatment history
Anticipate needs and intervene early
Ensure that treatment is available and
appropriate
(Hodas, 2008)
TIC within Suicide Prevention: Practices
• Help people…
– understand trauma history, symptoms &
behaviors, impact on life and how to change
– learn to recognize & control triggers
– Approach ‘failures’ as opportunities to learn
• Promote…
– self-expression
– acquisition of social skills
– coping & wellness
(Hodas, 2008)
Tool: WRAP Plan
WRAP Plan should address:
–
–
–
–
–
–
Preferred ways of calming
Triggers
Signs and symptoms of triggers
What people want helpers to do and not to do
What people want to be encouraged to do
Identification of others who can provide support
http://www.indianamentalhealthneeds.org/files/Advocate_WRAPIntro.pdf
(Hodas, 2008)
Trauma Resources
• National Center for Trauma-Informed Care
http://mentalhealth.samhsa.gov/nctic/
• National Center for Posttraumatic Stress Disorder
http://www.ncptsd.org
• National Child Traumatic Stress Network
http://www.nctsn.org
• International Society for Traumatic Stress Studies
http://www.istss.orgI
• International Society for the Study of Trauma and
Dissociation http://www.isstd.org
• The Anna Institute. http://www.annafoundation.org/
Sample of Models, Guides and Resources
The Anna Institute. http://www.annafoundation.org/
Developing Trauma-Informed Organizations, Inst. for
Health and Recovery. http://www.healthrecovery.org/
Risking Connection, Sidran Institute.
http://www.riskingconnection.com/
The Sanctuary Model, CommunityWorks.
http://www.sanctuaryweb.com/
Using Trauma Theory to Design Service Systems,
Fallot & Harris, Community Connections.
School and Teaching Resources
Helping Traumatized Children Learn
Massachusetts Advocates for Children 2005
http://www.massadvocates.org/helping_traumatized_children_learn
The Heart of Learning & Teaching Compassion, Resiliency & Academic Success
Wolpow, Ray; Johnson, Mona M.; Hertel, Ron; Kincaid, Susan O. 2009
http://k12.wa.us/CompassionateSchools/HeartofLearning.aspx
Creating Sanctuary in Schools 1995
Bloom, Sandra
http://www.sanctuaryweb.com/Documents/Sanctuary%20in%20the%20School.pdf
Child Trauma Toolkit for Educators
National Child Traumatic Stress Network
http://www.nctsnet.org/nctsn_assets/pdfs/Child_Trauma_Toolkit_Final.pdf
Credits
Multiple slides were taken from the work of…
• Gordan Hodas, Pennsylvania 2nd Annual
Suicide Prevention Conference, TraumaInformed Care & Youth Suicide Prevention
(2008)
• Janet McCord, Marian University of Fond
du Lac, Shneidman in a Nutshell:
Psychache and Suicide (2011)
Contact Information
Elizabeth Hudson, LCSW
Trauma-Informed Care Consultant
WI Dept. of Human Services
Division of Mental Health and Substance Abuse Services
608-266-2771
Elizabeth.Hudson@wisconsin.gov
Employed by University of Wisconsin School of Medicine and Public Health