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Division of Care and Treatment Services
TIC:
Trauma-Informed Care
Trauma-Informed ConnectionScott Webb, MSE
Trauma-Informed Care Coordinator
April 17, 2020
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Learning Objectives
▪ Define and identify key terminology and concepts
related to trauma
▪ Understand the significance of the Adverse
Childhood Experiences (ACE) Study as it relates to
mental illness across the lifespan
▪ Articulate what trauma-informed care is, and be
able to identify the five pillars of trauma-informed
culture change for an organization
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Recent Headlines
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“Adult disease can
best be understood as the manifestations of distant childhood events.
Dr. Vincent FelittiACE Principle Co-Investigator
August 2010
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Be Gentle on Yourself
BreatheSelf empathyPositive self-talkCount to tenUse fidgetsFeel feet on floorDoodleGet up and walk around
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Trauma Defined
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What is trauma?
▪ It is literally a wound. ♦ Greek derivation: (τραύμα)
▪ Disease of disconnection (Judith Herman, MD)
▪ Traumatic events are external, but they quickly become
incorporated into the mind. (Terr, 1990)
▪ It is extreme stress. (threat to life, bodily integrity, or
sanity)
▪ It is subjective.
▪ It lives in the body.
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What is trauma?
▪ It often interferes with relationships.
▪ It affects the fundamental beliefs about oneself
and others.
▪ It causes one to question their place in the world.
▪ It’s a lot more common than you think.
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Why are so many talking about
trauma?
▪ Disclosure
▪ Prevalence
▪ Science
▪ Services
▪ Hope
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Photo: Homeboy Industries
Father Gregory Boyle
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The Many Faces of Trauma
▪ Acute
▪ Complex
▪ Historical
▪ Sanctuary
▪ Vicarious
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Sandy Hook Columbine Cooperative, 2017
Impact of Trauma
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At least half of all adults in the U.S. have experienced one incident that was caused by a major
traumatizing event
(Briere and Scott, 2006)
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Sixty eight percent of the healthcare workforce have experienced at least one episode of violence, abuse
or neglect
(Maundler, Peladeu, Savage, et al. 2010)
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What Does the Prevalence Data Tell Us?
▪ Many with trauma histories have overlapping problems
with mental health, substance use disorders, physical
health and are victims or perpetrators of crime
▪ Those with traumatic lived experience are found across all
systems of care
S. Covington, Ph.D
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Adverse Childhood
Experiences (ACEs)
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ACE Study
It was designed to examine the health and social
effects of ACEs throughout the lifespan among
17,421 members of the Kaiser Health Plan in San
Diego County.
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ACE Study
What do we mean by ACEs?
▪ Childhood abuse and neglect
▪ Growing up with domestic violence, substance use
disorder, mental illness, parental discord, and/or
crime in the home
(Anda, 2013)
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▪ are common
▪ are intergenerationally passed
▪ have a cumulative effect—the higher the score, the higher the likelihood of health risk behaviors and poor health outcomes
▪ are NOT destiny!
Adverse Childhood Experiences:
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Types of Stress Responses
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of Wisconsin
residents have
at least 1 ACE
Findings from the 2015-2018 Behavioral Risk Factor Survey
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ACEs and Mental Health
5%8%
14%
29%
5%8%
14%
28%
10%
16%
24%
43%
0%
10%
20%
30%
40%
50%
0 ACEs 1 ACE 2-3 ACEs 4+ ACEs
Current Anxiety Frequent Mental Distress
Lifetime Depression Diagnosis
Findings from the 2017-2018 Behavioral Risk Factor Survey
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ACEs and Physical Health
7% 9% 10%15%
12% 14%17%
26%30% 32% 33%
40%
0%
10%
20%
30%
40%
50%
0 ACEs 1 ACE 2-3 ACEs 4+ ACEs
Asthma Fair/Poor General Health Obesity
Findings from the 2017-2018 Behavioral Risk Factor Survey
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Household Dysfunction
7%
16%
16%
23%
26%
Incarceration
Mental illness
Violence between adults
Parent separate/divorce
Substance abuse
2011-2015 Behavioral Risk Factor Survey
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28%
17%
10%
Emotional
Physical
Sexual
Abuse28% of Wisconsin residents grew up experiencing emotional abuse.
Findings from the 2011-2016 Behavioral Risk Factor Survey
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ACEs Impact Over Lifespan
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▪ Neurological
▪ Biological
▪ Psychological
▪ Social
▪ Mortality
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Trauma disrupts neurodevelopment
Person experiences trauma
Brain and body become overwhelmed; nervous system is unable to return to
equilibrium
Trauma goes untreated; person stays in “stress response” mode
Cues continue to trigger trauma (e.g. loud noises, smells, textures)
Person reacts to trauma cues from a state of fear
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“The peace of mind
you deserve in the present is held hostage by the terror of your past
-Lily Burana
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Illustration: The Triune Brain, By Lchunhori at English Wikipedia
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Healthy Brain and Abused Brain
CDC
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Reminders or “Triggers”
A trigger can be a person (or approach), place,
thing, time, event, date, smell, or texture.
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Reminders or “Triggers”
▪ Lack of control
▪ Threats or feeling threatened
▪ Isolation
▪ Authority figures
▪ Being told what to do
▪ Lack of privacy
▪ Separation or loss
▪ Transitions or disruptions in
routine
▪ Being touched or
watched
▪ Loud noises
▪ Intrusiveness
▪ Being locked in a room
▪ Being ignored
▪ Condescending looks
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Elder-Specific Traumatic Experiences
▪ Loss of spouse and peers
▪ Chronic and life-threatening diagnosis
▪ Physiological changes, limitations and disability
▪ Cognitive and memory loss
▪ Loss of roles and resources
▪ Increased dependence on caregivers
▪ Unavailability of caregivers (COVID-19)
Question: How does having a trauma history compound these later-in-life traumas?
Gabriela Grant, 2019
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Trauma and the Elderly
One thing to keep in mind when considering how
often older adults face new traumas or stressors…
Any change involves loss.
Loss needs to be grieved.
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Trauma and the Elderly
Many factors make it more or less difficult for elders
before, during, and after traumatic events
♦ Impaired cognition, mobility, or senses
♦ Decreased or unavailable social network (COVID-19)
♦ Mental or medical problems
♦ History of exposure to extreme traumatic stressor
♦ Substance use disorder
♦ Language or cultural barriers
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Trauma Can Complicate Aging
▪ Trauma poses a threat to the successful aging process by interfering with interpersonal relations and productive activity (Cisler et al., 2010; Rowe and Kahn, 1997)
▪ Contrary to previous assertions of resiliency in older adult populations, there is reason to suspect greater vulnerability to emotional difficulties following exposure to traumatic stressors in this population (Grey and Acierno, 2002)
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Post-Traumatic Stress Disorder
Assessment for Elders▪ Post Traumatic Disorder Checklist
♦ Validated for older adults (Hudson, et al., 2008)
▪ Trauma Symptom Checklist – 40 (Briere)
♦ General for adults (age specific for children)
▪ Stressful life experiences checklist
▪ ACE Questionnaire
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Brief Trauma Screen
▪ Do you feel safe speaking to me today?
♦ If not, what would help you feel safer?
▪ Do you feel safe at home today?
♦ If not, how can we help you feel safer?
▪ Did you feel safe at home as a child?
♦ If not, how does that affect you today?
Developed by Gabriela Grant
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The Trauma World View
• No place is safe• My own actions, thoughts,
and feelings are unsafe• Other people are unsafe and
can’t be trusted• I expect crisis, danger and
loss• I have no worth and no
abilities
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Outward Expressions Inward Expressions
Explaining, not Excusing Behaviors
▪ Anger or defiance
▪ Violence towards others
▪ Truancy
▪ Criminal acts
▪ Perfectionism
▪ Withdrawal
▪ Substance use disorder
▪ Violence towards self
▪ Spacing out
▪ Perfectionistic
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A Trauma World View Requires a Shift
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Do No Harm
“We need to presume the clients we serve have a
history of traumatic stress and exercise universal
precautions by creating systems of care that are
trauma-informed.”
(Hodas, 2005)
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Over-Arching Concept
Trauma must be seen as the expectation, not the
exception, in behavioral health treatment systems
(Rosenberg, 2011)
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Being Trauma-Informed
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What is Trauma-Informed Care?
▪ Principle-Based culture change process
▪ Acknowledges the pervasiveness of trauma
▪ Focused on how trauma may effect an
individual’s life and their response to support
services
▪ Safety for all
▪ Atmosphere of trust
▪ Compassionate collaboration
▪ Strengths-based
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What is Trauma-Informed Care?
▪ Aims to avoid re-traumatization
▪ Appreciates many problematic
behaviors began as
understandable attempts to cope
▪ Strives to maximize choices for
the survivor and control over the
healing process
▪ Seeks to be culturally competent
▪ Understands each survivor in the
context of life experiences and
cultural background
(Alvarez and Sloan, 2010)
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Trauma-Informed Care
▪ Is not an intervention to address posttraumatic
stress disorder
▪ Is not a “flavor of the day” approach
▪ Is not age limited
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Wisconsin’s TIC guiding principles
“The oldest medicine
in the world is love and
compassion”
VADM Vivek Murthy, M.D.
Former United States
Surgeon General
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Working with People with Traumatic
Experiences ▪ They are not victims.
▪ The labels we use to describe these people keep them
trapped in their story.
▪ When we label, we judge.
▪ When we judge, we lose the ability to connect
meaningfully with these people.
▪ They are people who have had a unique opportunity to
develop a set of strengths and resiliency factors we need to
understand – they need to feel safe enough to share with
us
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Working with People with Traumatic
Experiences ▪ This process starts before they walk in the door: What
is your organization’s reputation in the consumer
community? (Do you know?)
▪ Requires us to become aware of their awareness.
♦ Is the waiting room calm and welcoming?
♦ Are the support staff friendly and helpful?
♦ What are some perceptual barriers we may not have
thought about?(Michael G. Bricker, MS, CADC-II, LPC, 2018)
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Five Primary Trauma-Informed Care Values
• Safety• Trustworthiness• Choice• Collaboration• Empowerment
Fallot and Harris, 2006
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Value-Based Practice: Safety
▪ Create a welcoming, calming environment
▪ Maintain respectful physical and emotional
boundaries
▪ Provide a safe place to talk
▪ Be open to outside parties, advocacy, and clinical
consultants
▪ Ask about current abuse and address current risks
to safety (Fallot and Harris, 2002)
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Comparison
TraditionalKey Question: “What’s
wrong with you?”
▪ Elder isn’t fitting well
here, has limited social
skills, not making
friends, isolating
▪ Not remembering
anything
Trauma-InformedKey Question: “What happened to you?”
▪ Experienced a significant loss or transition recently?
▪ Is there a medical condition? Medication interaction? Trauma history?
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Re-traumatization
▪ A situation, attitude, interaction, or environment
the replicates the events or dynamics of the
original trauma (a trigger)
▪ Can be obvious, or not
▪ Usually unintentional
▪ Always hurtful
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Responding to People in Need
Listen (Active listening)ValidateNormalizeAssistAvoid re-traumatization
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More on Validation
▪ “What happened was not your fault”
▪ “You are not to blame for what happened to you”
▪ “Thank you for trusting me with such a personal
and private experience”
▪ “You deserve help in dealing with something so
difficult. Would you like me to connect you with
someone you could talk to about this?”
(Aurora Health Care, 2016)
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What Does TIC Look Like?
▪ Avoid forcing eye contact
▪ Be aware of your proximity
▪ Avoid asking too many questions
▪ Pace client meetings by offering breaks
(water, stretch, etc.)
▪ Draw upon past success
▪ Ask before touching or hugging
▪ Provide choice when possible
▪ Ask about the client’s goals and priorities
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What Does TIC Look Like?
▪ During emotional times ask “How can I support you right
now?”
▪ When the trauma story overwhelms or leaves you
speechless, be willing to sit in supportive silence
▪ Provide clear information about when, where, and by
whom services will be provided
▪ Be prepared to repeat information many times; repetition
is commonly needed when patients are working with an
overwhelmed nervous system
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Value-Based Practice:
Compassionate Communication▪ Use person-first language (not diagnosis-first
language)
▪ Empathy before education
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Value-Based Practice:
Compassionate CommunicationAvoid using de-humanizing language:
▪ Manipulative
▪ Non-compliant
▪ Attention-seeking
(Aurora Health Care, 2016)
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Important to Broaden Our View of TIC62
▪ For years we have thought about TIC in age
groups: kids, adults, and older adults
▪ We need to begin to think about TIC in ages
across the lifespan!
Gloria Dixon, DNP, PMHN-BC, 2018
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Important to Broaden Our View of TIC63
The following concepts apply to all ages:▪ Person-centered planning▪ Compassionate communication▪ Confidentiality▪ Comfort▪ Trust and respect▪ Recovery concepts▪ Collaboration▪ Education for all staff
Gloria Dixon, DNP, PMHN-BC, 2018
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Adult Protective Service and Aging
Staff Interventions64
• Psychological First Aid for Seniors (Crisis Intervention)http://amhd.cbcs.usf.edu/docs/pfanh2ed.pdf
• Seeking Safety (PTSD and Substance Use Disorder)www.seekingsafety.org
• Cognitive Behavioral Therapy for Late-Life Depressionhttp://oafc.stanford.edu/projects/cbt.html
• IMPACT (Depression)http://impact-uw.org
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Adult Protective Service and Aging
Staff Interventions65
• Responding to Violent Crimes Against Persons with
Disabilitieshttp://www.safeplace.org/page.aspx?pid=358
• Preventing Suicide and Promoting Well-Beinghttp://store.samhsa.gov/product/SMA10-4515
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Be Attentive
Language Matters
Your Words Have Power
Use Speech Free From Labels,
Jargon, and Judgments
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Thank You!
Scott A. Webb, MSE
608-266-3610
Join the TIC Email ListVisit dhs.wisconsin.gov/tic to sign up to receive email notices for
trauma-related research, resources, training opportunities, etc.