trauma informed system of care: changing our perspective
DESCRIPTION
Trauma Informed System of Care: Changing Our Perspective. Raul Almazar, RN, MA Senior Consultant National Center for Trauma Informed Care. What is Trauma?. Definition ( NASMHPD , 2006 ) - PowerPoint PPT PresentationTRANSCRIPT
Trauma Informed System of Care:
Changing Our Perspective
Raul Almazar, RN, MASenior ConsultantNational 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
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
almazarconsulting.com
DEFENDING CHILDHOOD
• PROTECT• HEAL• THRIVEREPORT 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.
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
Trauma Assessment
AndTreatment
Almazar Consulting
Trauma Assessment And Treatment
Universal Precautions
Trauma InformedCare
Almazar Consulting
Person Served
Trauma Sensitive
Trauma Assessment and TX
Trauma Informed System
Non-Coercive
Non-Controlling
Partnerships Collaboration
Resiliency Recovery
Hope Healing
Almazar Consulting
ACE Study
Compares adverse childhood experiences against adult status, on average, a half century later
Almazar Consulting
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)
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
• 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
The higher the ACE Score, the greater the likelihood
of :
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
29
Adverse Childhood Experiences
Neurobiological Impacts and Health Risks
Long-term Health and Social Problems
The more types of adverse childhood experiences…
The greater the neurobiological impacts and health risks, and…
The more serious the lifelong consequences to health and well-being
Emotional Problems
Almazar Consulting
Almazar Consulting
Childhood Experiences Underlie
Chronic Depression
0 1 2 3 >=40
1020304050607080
Women Men
ACE Score% W
ith
a L
ife
tim
e H
is-
tory
of
De
pre
ss
ion
Almazar Consulting
Childhood Experiences Underlie Suicide
Series10
5
10
15
20
25
% A
tte
mp
tin
g S
uic
ide
ACE Score1
2
0
3
4+
• 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 suicideMen are 4 times as likely as women to complete suicide.
Almazar Consulting
0 1 2 3 4 5 6 >=70
2
4
6
8
10
12
NoYes
ACE Score
Ever
Hallu
cin
ate
d*
(%)
*Adjusted for age, sex, race, and education.
ACE Score and Hallucinations
Almazar Consulting
Series10
5
10
15
20
25
30
35
40
ACE Score and Impaired Memory of Childhood
Perc
en
t W
ith
Mem
ory
Imp
air
men
t (%
)
ACE Score
ACE Score
1 2 3 4 5
Health Risk Behaviors
Almazar Consulting
Almazar Consulting
Adverse Childhood Experiences and Current Smoking
0 1 2 3 4-5 6 or more0
4
8
12
16
20
ACE Score
%
Almazar Consulting
Childhood Experiences and Adult Alcoholism
Series10
2
4
6
8
10
12
14
16
18
%
Alc
oh
oli
c
ACE Score0
1
23
4+
ACE Score and Intravenous Drug Use
0 1 2 3 4 or more0
0.5
1
1.5
2
2.5
3
3.5
ACE Score
% H
av
e I
nje
cte
d
Dru
gs
N = 8,022 p<0.001Almazar Consulting
Almazar Consulting
“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 self-destructive or is it a
desperate attempt at self-healing, albeit while
accepting a significant future risk?”
(Felitti, 1998)
• 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
Series10
5
10
15
20
25
30
35%
Re
po
rtin
g R
ap
e
ACE Score
0
1
23
4+
Almazar Consulting
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
ACEs Underlie Domestic Violence
Almazar Consulting
Almazar Consulting
Almazar Consulting
Adverse Childhood Experiences and Likelihood of > 50 Sexual Partners
0 1 2 3 4 or more0
1
2
3
4
ACE Score
Ad
jus
ted
Od
ds
Ra
tio
ACE Score and Unintended Pregnancy or Elective Abortion
0 1 2 3 4 or more0
10
20
30
40
50
60
70
80
Unintended Pregnancy Elective Abortion
ACE Score
%
ha
ve
Un
inte
nd
ed
PG
, o
r A
B
Almazar Consulting
Almazar Consulting
Adverse Childhood Experiences andHistory of STD
0 1 2 3 4 or more0
0.5
1
1.5
2
2.5
3
ACE Score
Ad
jus
ted
Od
ds
Ra
tio
Almazar Consulting
Sexual Abuse of Male Children and Their Likelihood of Impregnating a Teenage Girl
Not 16-18yrs 11-15 yrs <=10 yrs abused Age when first abused
Perc
en
t w
ho
imp
reg
nate
d
a t
een
ag
e g
irl 1.3x 1.4x
1.8x
1.0 ref
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
Never Once, Sometimes Often Very Twice often
P
erc
en
t w
ho h
ad
a
t
een
pre
gn
an
cy
Pink =selfGreen =mother
ACE Score and Indicators of Impaired Worker Performance
Absenteeism (>2 days/month
Serious Financial Poblems
Serious Job Problems
0
5
10
15
20
25
0 1 2 3 4 or more
ACE Score
Pre
vale
nce
of
Im
pai
red
P
erfo
rman
ce (
%)
Almazar Consulting
Almazar Consulting
“What happened to you?” instead of
“What’s wrong with you?”
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?”
Almazar Consulting
All behavior has meaning
Symptoms are ADAPTATIONS
Comfort vs. Control
We build on success not deficits
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”?)
KEY SYSTEMS
FOR RESILIENCE
Nourishment
Protection
GrowthWholeness
EXAMPLES OF PROGRAM & POLICY ACTIONS
• 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)
• 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.
Punishment vs. Compassion
• 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%
Killarney Secondary School 2010 – 2013
Vandalism, false fire alarms, locker break-ins drug deals common
Lincoln High School 2009 – 2011
Kids kicked out of other schools, last chance; gangs controlled building.
Neurodevelopment of ChildhoodBruce 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 survivalfor human beings is the clan.
Evolutionary pressure which resultedin our species was applied to theclan, not the individual.
We are unavoidably inter-dependentupon each other.
The compartmentalization ofWestern 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 HouseholdsPrivacy 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
Mother
Caregiver
Family and Friends
Peers, TeachersCommunity
Rauch Brain scans
(Restak, 1988)
AmygdalaBecomes “irritable”,Increasingly sensitive to triggers
Prefrontal CortexFrontal lobes shut down or decrease activity to ensure instinctive responding
ThalamusAbility to perceive new information decreases
TriggeringStimulus
Bottom-Up Responses
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
S Stimulus
Sensory Thalamus Amygdala
Cortex
Very Fast
SlowerHippocampus
Response
(LeDoux, 1996)
Between Stimulus and Response
S Stimulus
Sensory Thalamus AmygdalaVery Fast
Slower
Response
Cortex
Hippocampus
Neuroregulatory InterventionPsychotherapy
Psychopharmacology
Social Environmental Intervention
(LeDoux, 1996)
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
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:
Slide 82
Olff, Langeland et alGender Differences in PTSD
2007, Psychological Bulletin
Male FemaleRate 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
•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
Prior Traumatization No difference
Male FemaleCognitive Appraisal •Higher levels of
perceived control•Lower reliance on blaming others
•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 FemaleCoping • Instrumental Mastery
• Fight or Flight•Tend and Befriend• Freezing• Passive avoidance
Perry’s theoryPsychological 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 FemaleHealth Outcomes More aggressive
behaviors• 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
DevelopmentRaul Almazar, RN, MASenior ConsultantSAMHSA’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
Trauma lives in the body. The body has ways to indicate to us that a
threat cue is perceived.
Biological
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 Trauma-Informed Approach
Slide 105
• Safety
• Trustworthiness and Transparency
• Peer Support
• Collaboration and Mutuality
• Empowerment, Voice, and Choice
• Cultural, Historical, and Gender Issues
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?
Slide 107
Principles of TIC:SAFETY
Raul Almazar, RN, MASAMHSA National Center for Trauma Informed CareNational Association of State Mental Health Program Directors
Contact info:[email protected]
Safety
almazarconsulting.com
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
Four Types of Safety
Adapted from Sandra Bloom’s Sanctuary Model:
Physical SafetyPsychological SafetyMoral SafetySocial 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:
Empowerment, Voice and Choice) Firm belief in Recovery, Recovery as a moral imperative (
Core TIA Principle: Peer Support) Sense of integrity, courage and justice Providing and receiving the most effective treatment Attending to power differentials to promote health and
healing (Core TIA Principle: Collaboration and Mutuality
Practicing democratic principles
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 externalenvironmental 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 itscapabilities, 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, MATSAMHSA National Center for Trauma Informed Care
National Association of State Mental Health Program Directors
Contact info:[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, MASAMHSA National Center for Trauma Informed Care
National Association of State Mental Health Program Directors
Contact info:[email protected]: @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 trauma-
informed 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
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
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
Slide 156
Discussion
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 decision-making.
Everyone has a role to play; one does not have to be a therapist to be therapeutic.
Slide 158
Examples of Collaboration
Slide 159
Discussion
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
Slide 162
Discussion Question
Slide 163
How can you use your clients’ strengths?
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 trauma-informed 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
Almazar Consulting
SAMHSA’s National Center for Trauma Informed Care