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Trauma-informed Care in Long-term CareScott A Webb, MSE, LCSW,

Wisconsin Department of Health Services

May 16, 2019

Scott Webb, LCSWTrauma-Informed Care CoordinatorMay 16, 2019

TIC:Trauma-Informed Care

Trauma-Informed Connection

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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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What We Now Know“Adult diseases 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 YourselfBreatheSelf empathyPositive self-talkCount to tenUse fidgetsFeel feet on floorDoodleGet up and walk around

Photo: Pixabay.com

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What is Trauma?• Literally a wound• Traumatic events are external, but quickly become

incorporated into the mind (Terr, 1990)• Disease of disconnection (Judith Herman)• Creates lasting adverse effects on the individual’s physical,

social, emotional, or spiritual well-being• Is subjective• Lives in the body “The Body Remembers”• Interferes with relationships• More common than you think

Why Are So Many Talking About Trauma?

• Disclosure• Prevalence• Science• Services• Hope

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Father Gregory Boyle

Photo: Homeboy Industries

ACUTE• Adult onset• Single event• Adequate child

development

COMPLEX• Early onset• Multiple events over time• Highly invasive• Interpersonal• Stigmatizing (shame)

HISTORICAL• Collective and cumulative

emotional and psychological wounding across generations

• Creates survivor guilt, depression, low self-esteem, numbing out, and anger

SANCTUARYOvert and covert events in settings socially sanctioned as safe• Medical, mental health and

substance abuse services• Foster care• Schools• Places of worship

VICARIOUSThe experience

of learning about another person’s

trauma and experiencing

trauma-related distress as a result of this exposure.

Types of Trauma

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Source: Sandy Hook Columbine Cooperative, 2017

Estimated that 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)

Ninety percent of behavioral health consumers have been exposed to a traumatic event; most have multiple exposures (Muesar, 1998)

Impact of Trauma

ACE StudyIt 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 StudyWhat 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)

Adverse Childhood Experiences• Are common• Can have long-term, damaging consequences• Can happen in any family• Have a cumulative effect—the higher the score, the

higher the likelihood of health risk behaviors and poor health outcomes

• May be a significant driver of health care spendingPhoto: Shutters

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ACE QuestionnaireAbuse• Psychological (by parents)• Physical (by parents)• Sexual (by anyone)• Physical neglect• Emotional neglect

Household with• Substance abuse• Mental illness• Separation or divorce• Domestic violence• Imprisoned household

member

57% of Wisconsin residents have at least one ACE.have at least one

2011-2015 Behavioral Risk Factor Survey

E.2011‐2015 Behavioral Risk Factor Survey

ACEs - Wisconsin

Photo: Shutterstock.com

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Abuse

2011‐2015 Behavioral Risk Factor Survey

2011‐2015 Behavioral Risk Factor Survey

ACEs Correlated with Poor Mental Health Outcomes

8%

15%

22%

36%

4%9%

12%

24%

0%

10%

20%

30%

40%

0 1 2 to 3 4+

Ever Diagnosed with Depression

Frequent Mental Distress (14+ Bad MH Days in last 30)

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ACE Count and Current Smoking

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2011‐2015 Behavioral Risk Factor Survey

ACEs Impact Over Lifespan

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Neurological Biological Psychological Social Mortality

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The Pair of ACEs

Trauma disrupts neurodevelopmentPerson 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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Brain Development• Each developmental stage depends on the previous stage.• Trauma disrupts the chemistry of the brain and can

predispose people to alcohol and drug use, eating disorders, self-injurious behavior and mental health problems. (Covington, 2016)

• Trauma impacts each level of development and the ability to move to the next stage.

• When trauma occurs in childhood, it can have lasting effects on brain development. (Covington, 2016)

• In times of stress, we regress.

Triune Brain Model

Chun-Hori 2007Chun-Hori 2007

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Healthy Brain and Abused Brain

CDC

Healthy Brain and Abused Brain

Bruce D. Perry, MD, Ph.D. 1997

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Elder-Specific Traumatic Experiences

• Loss of spouse and peers• Chronic and life-threatening diagnoses• Physiological changes, limitations and disability• Cognitive and memory loss• Loss of roles and resources• Increased dependence on caregiversQuestion to consider: How does having a trauma history compound these later-in-life traumas?

Gabriela Grant, 2018

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Trauma and the ElderlyOne 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 ElderlyMany 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− Limited finances− Mental or medical problems− History of exposure to extreme traumatic stressor− Substance use disorder− Language or cultural barriers

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 – average age 59

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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 Gabriella Grant32

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No place is safe

Other people are unsafe

and can’t be trusted

My own actions, thoughts, and

feelings are unsafe

I expect crisis, danger and

loss

I have no worth and no

abilities

The Trauma World View

Photo: Pixabay.com

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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)

Over-Arching ConceptTrauma must be seen as the expectation, not the exception, in behavioral health treatment systems(Rosenberg, 2011)

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The Transformational Question

“What’s wrong with 

you?” 

“What happened to 

you?” 

“What’s right with you?”

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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Five Primary TIC Principles

TIC Culture Change

Tru

stw

ort

hin

ess

Ch

oic

e

Co

llab

ora

tio

n

Em

po

wer

men

t

Saf

ety

(Fallot and Harris, 2006)

ComparisonTraditionalKey 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

What is Trauma-Informed Care?• A principle-based culture change process• Acknowledgement of the pervasiveness of trauma• It focuses on how trauma may effect an individual’s life

and their response to behavioral health services (ages across the life span)

• Safety for both participants and providers• Atmosphere of trust• Compassionate collaboration• Strengths-based

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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

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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Value-Based Practice: Compassionate Communication

• Use person-first language (not diagnosis-first language)

• Empathy before education

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 TIC Looks LikeDuring emotional times ask: “How can I support you right now?”

When the trauma story 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 consumers are

working with an overwhelmed nervous system.

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Responding to People in Need

Listen (Active listening)Validate (That must be very hard)NormalizeAssist (Grounding techniques, making appropriate referrals)Avoid re-traumatization

Photo: Pixabay.com

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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)

We Need to Broaden Our View of TIC• 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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We Need to Broaden Our View of TIC• 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 Interventions

• 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 Depression• http://oafc.stanford.edu/projects/cbt.html

• IMPACT (Depression)• http://impact-uw.org

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Adult Protective Service and Aging Staff Interventions

• Responding to Violent Crimes Against Persons with Disabilities• http://www.safeplace.org/page.aspx?pid=358

• Preventing Suicide and Promoting Well-Being• http://store.samhsa.gov/product/SMA10-4515

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Thank You!Scott A. Webb, MSE, LCSW608-266-3610scott.webb@dhs.wisconsin.gov

Join the TIC Email ListVisit dhs.wisconsin.gov/tic to sign up to receive email notices for

trauma-related research, resources, training opportunities, etc.

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This material was prepared by Lake Superior Quality Innovation Network, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The materials do not necessarily reflect CMS policy. 11SOW-MI/MN/WI-C2-19-47 041019

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