Traumainformed
Practice (TIP)
Diane Smylie
Substance Use Knowledge Exchange Leader
dsmylie@cw.bc.ca
Background
• Provincial TIP initiative (TIP Guide & Curriculum)
• Regional work supported by provincial KE Team (DTFP)
• Current work at BC Mental Health and Substance Use
Services – Children and Women’s programs
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What? Why? & How?
• Defining trauma
• Prevalence and links to health and mental health
• The rationale for trauma-informed practice
• Basic trauma-informed practice concepts and definitions
• TIP resources and examples of how TIP is being
implemented in various service contexts
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PREVALENCE & LINKS
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Trauma and PTSD
The terms violence, trauma, abuse, and post-traumatic
stress disorder (PTSD) often are used interchangeably.
One way to clarify these terms is to think of trauma as a
response to violence or some other overwhelmingly
negative experience (e.g., abuse).
Trauma is both an event and a particular response to an
event. The response is one of overwhelming fear,
helplessness, or horror. PTSD is one type of disorder
(response) that results from trauma.
(Covington, 2003)
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Definition of Historical Trauma
“The cumulative emotional and psychological wounding across
generations, including the lifespan, which emanates from
Dr. Maria Yellow Horse Brave Heart, 2003
massive group trauma”
“When cumulative HT events are coupled with high rates of
contemporary lifetime trauma and interpersonal violence, as
well as high rates of chronic stressors, such as daily
discriminatory events, together, these historical and
contemporary events undermine physical, spiritual, and
psychological health and well-being in complex and multifaceted
ways.
Walters et al., 2011
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Trauma is common
among Canadians
In a representative Canadian sample, 76.1% of Canadians had
been exposed to at least one traumatic event in their
lifetime, 9.2% met the criteria for PTSD in their life time. (Van
Ameringen, Mancini, Patterson & Boyle, 2008)
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Trauma is common among people with
mental health & substance use concerns
• Majority of adults and children in inpatient psychiatric
and substance use treatment settings have trauma
histories (Lipschitz et al, 1999; Suarez, 2008; Gillece, 2010)
• Survey of teens in substance use treatment > 70% had
history of trauma exposure (Suarez, 2008)
• 2/3 adults in substance use treatment report child abuse
and neglect (SAMHSA, CSAT, 2000)
SAMHSA, 2012
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What is Trauma?
• It can be a single event
• Often multiple events over time (complex, prolonged
trauma)
• An interpersonal violence or violation, especially at the
hands of an authority/trust figure is especially damaging
• Trauma occurs in an interaction of person by event by
context (Harvey & Tummala-Narra)
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What does trauma do to us?
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.
Bessel A. van der Kolk , MD
http://www.traumacenter.org/products/pdf_files/Preprint_Dev_Trauma_Disorder.pdf
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Trauma Effects
Physical
Unexplained chronic pain
or numbness
Emotional or
Cognitive
Loss of meaning, or faith
Anxiety
Loss of connection to:
self, family, culture,
community, nature, a
higher power
Anger management
Headaches
Compulsive and
obsessive behaviours
Breathing problems
Digestive problems
Interpersonal
Depression
Stress-related conditions
(e.g., chronic fatigue)
Sleep problems
Spiritual
Feelings of shame, guilt
Dissociation
Self-blame
Being overwhelmed with
memories of the trauma
Self-hate
Difficulty concentrating,
feeling distracted
Fearfulness
Emotionally numb/flat
Loss of time and memory
problems
Suicidal thoughts
Feel completely different
from others
No sense of connection
Feeling like a ‘bad’
person
Frequent conflict in
relationships
Behavioural
Substance use
Lack of trust
Difficulty enjoying time
with family/friends
Difficulty establishing
and maintaining close
relationships
Avoiding specific places,
people, situations (e.g.,
driving, public places)
Experiences of revictimization
Shoplifting
Difficulty setting
boundaries
Disordered eating
Self-harm
High-risk sexual
behaviours
Suicidal impulses
Gambling
Isolation
Justice system
involvement
Haskell, 2003; Haskell, 2001; Schachter et al., 2009
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ACE’s Study
Death
If not disrupted
conception
Mechanisms by which Adverse Childhood Experiences influence
Health and Well-being throughout the lifespan
Felitti & Anda, 2010
WHAT DOES THIS MEAN FOR
HEALTHCARE SETTINGS/PROVIDERS?
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Trauma Awareness
Consideration of the
profound neurological,
biological, psychological &
social effects of trauma &
violence on all of us.
For more information on
the neurobiology of
trauma:
www.childtrauma.org
www.traumacenter.org
Margaret E. Blaustein PhD. & Kristine M. Kinniburgh LICSW
“In many cases, people who endured childhood abuse and
neglect develop what might seem like a bewildering array
of problems throughout their lives.
Many service providers, and in many cases the survivors
themselves, can misunderstand these difficulties as selfinflicted because they do not understand how abuse,
trauma and their effects reverberate throughout a person’s
Haskell in Poole et al. 2012
life.”
Issues affecting service access &
engagement
•
•
•
•
Service entry points and transitions can be difficult to navigate
Services often lacking coordination and collaboration
Service settings and processes can be confusing
Service providers can have a tendency to reduce people to
labels (risky behaviors/ people)
• Services sometimes prioritize provider needs /routines
• Physical settings can be unwelcoming
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Trauma effects that can affect
engagement
•
•
•
•
Difficulty with trust and relationships
Reluctance to engage and quick to drop out
Vigilance and suspicion
Previous traumatic experience caused by health care
system/providers
• Ambivalence to give up or change coping mechanisms
• Current violence/trauma – lack of agency
Harris & Fallot, 2006
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What is “Re-traumatization”
• A situation, attitude, interaction or environment that
replicates the events or dynamics of the original trauma
and triggers the overwhelming feelings and reactions
associated with them
– Can be obvious or not so obvious
– It is usually unintentional
– It is always harmful – often exacerbating the very
symptoms that people are seeking help for
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Jennings, 2013
Retrieved from: theannainstitute.org
How are our values and assumptions affecting people?
Are we sometimes overwhelmed or triggered?
How does this affect our interactions with colleagues?
TRAUMA-INFORMED & TRAUMA
SPECIFIC PRACTICES
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Trauma-informed
• Value based with core principles
• Embed principles in all aspects of service
• Awareness of connections between trauma, mental
health, substance use and health
• Universally offered
• Cultures of non-violence, learning and collaboration
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TIP Key Principles
1.
Trauma Awareness
2.
Emphases on safety and trustworthiness (includes cultural safety)
3.
Opportunity for choice, collaboration
and connection
4.
Strengths based and skill building
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Trauma specific services
• Offered in a trauma-informed environment
• Focus on treating trauma through therapeutic
interventions
• Specialized skills
• Offered with consent to people who choose trauma
specific treatment
• Based on a detailed assessment
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IN ACTION
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TIP can be seen in a change in the way we
view people
Shift from: “What is wrong”
to “What happened”
Change in language away from:
• Controlling
• Paranoid
• Manipulative
• Uncooperative
• Attention seeking
• Drug seeking
• Not believable, etc.
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Nancy Poole, 2011
Reframing Language
From…
To…
Controlling
The individual seems to be trying to
assert their power
Manipulative
The individual has difficulty asking for
what they want
Attention seeking
The individual is trying to connect the
best they can
Symptoms
Adaptations
Borderline
The individual is doing their best given
their early experiences
Malingering
The individual is seeking help in a way
that feels safer
Physical Environment
Consider:
• Signage with welcoming messages, avoiding “do not”
messages
• Waiting areas - comfortable and inviting
• Lighting in outside spaces
• Accessibility and safety of washrooms
• In counselling rooms – choice about whether door is
open or closed
Fallot & Harris, 2009, &Ontario Guidelines, 2013
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culturalcompetency.ca
A Story of Change
"At first, it was hard to see if attending the course made much of a difference in my day to day work. I learned
a lot but was trying to figure out how it would help me in an ER. While thinking about this, I couldn't help but
see stigma against people with mental health AND addiction problems everywhere. It was like it was always
there but I couldn't see it. The hardest part for me was that I couldn't not see, especially with colleagues that I
had come to admire. The disapproving glances, the sighing and rolling of the eyes, the ignoring and running
away, the interrupting and telling people what to say and do before they even had a chance to understand
what was happening to them - the name calling - 'bed cloggers, frequent flyers - and even 'human waste' is
used as code. It became too much to handle and I was being traumatized by my coworkers. I took a chance
and confided in another nurse who had also taken the CAP course and she felt the same. Then, we reached
out to another CAP graduate and then we are three. We started to build confidence in our way of engaging
with all people with genuine concern and attunement. Slowly, we became know as the 'bleeding hearts' and
we wear that badge proudly. When we heard about TIP, we jumped at the chance to be part of the
appreciative inquiry and that even built our confidence more. You see working in an ER isn't so much about
the patients, its about working around a burned out staff and trying to fit in."
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TIP Organizational Culture
• non-violence
• open communication
• emotional intelligence
• social responsibility
• inquiry and social learning
• growth and change
• democracy
Bloom, 2005
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Self awareness & compassion for all…
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Moments to Milestones: Engaging with People who use Substances
This 30-minute video is intended as an education resource for first
responders, including police, paramedics and emergency room staff. Also,
this video has relevance for anyone working with people who use
substances. It illustrates the remarkable, positive difference that can be
made when people who use substance are approached in an attuned
manner that fosters respect, compassion and inclusion.
www.youtube.com/watch?v=AHzvlMUoUYE
Examples of what’s happening in BC
• Vancouver Coastal Health – TIP Champions
• BC MHSUS – Children’s & Women’s programs
• Cross health authority MHSU dialogues
(Jessie.MatherLingley@bcmhs.bc.ca if interested)
• Provincial virtual CoP site
• Appreciative inquiry with interested teams and groups
• MCFD is developing a supplementary TIP Guide
Funding for this event has been provided in part by the Government of Canada, through British
Columbia’s Drug Treatment Funding Program - Strengthening Substance Use Systems Initiative. The
views expressed herein do not necessarily represent the views of the Government of Canada
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Questions?
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