Understanding Trauma and Why we Must Address It - PowerPoint Presentation

Slide1

Understanding Trauma and Why we Must Address It

Office

of Mental Health

Original presentation: March

2010Slide2

Acknowledgement

The New York State Office of Mental Health wishes to acknowledge the contributions of the National Association of State Mental Health Program Directors (NASMHPD) and its Office of Technical Assistance (formerly NTAC) for many of the following slides

.

The presentation has been updated to include DSM-5 definitions.Slide3

Objectives

Define Trauma and Trauma-Informed

Care

Review Prevalence and

Implications

Compare Trauma-Informed and Trauma-Insensitive

Systems

Identify

Core Elements of Organizational CommitmentSlide4

Trauma-Informed Care:

Competency Assessment

Ask if your organization…

Does

More Harm

Lacks Capacity

Is Trauma-Neutral

Is Trauma-Sensitive

Is Trauma-Informed

Is Trauma-ProficientSlide5

What is Trauma?

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 disaster

DSM-5 (APA 2013):

The previous edition, DSM-IV,

had addressed PTSD as an anxiety

disorder.

The DSM-5 includes a new

chapter

on

Trauma- and Stressor-Related Disorders.

Trauma includes:

direct experience of

the traumatic

event;

witnessing

the traumatic event in person;

learning

that the traumatic event occurred to a close family member

or

close friend

(

with the actual or threatened death being either violent or accidental); or

experiences

first-hand repeated or extreme exposure to aversive details

of

the traumatic event (not through media, pictures, television or movies

unless

work-related

).Slide6

Traumas Most Likely To Lead to Serious Mental Health Problems in Youth:

Sexual & physical abuse, neglect, emotional abuse, abandonment, poverty, sudden and traumatic loss

A

severe

one-time

or repeated

event (Yes, even just once)

Actions

perpetrated by someone known

Acts

that betray

trust

Generally

speaking,

the most harmful trauma experiences tend to be those that were perpetrated by someone close

-

someone

well-known

to the

victim -

and/or were:

Intentional

Repeated

Prolonged

And the earlier

in life it

happened,

the

more profound the

impact

on brain

development.Slide7

One-time events can be

as

traumatic

as repeated events. We

do not want to minimize single occurrences like a rape, a serious automobile accident, or being involved in a natural disaster, like Hurricane

Katrina or Irene, or

Superstorm

Sandy. Obviously

these types of events can be devastating.Slide8

Prevalence of TraumaMental Health Population - US

90% of public mental health clients have been exposed to trauma

Muesar

et al., 2004.

Muesar

et al.,

1998

51-98% of public health clients have been exposed to trauma

Goodman

et al., 1997.

Muesar

et al.,

1998

Most have multiple experiences with trauma

Muesar

et al., 2004.

Muesar

et al.,

1998

97 % of homeless women with SMI have experienced severe physical & sexual abuse, and 87% experience this abuse both in childhood and adulthood

Goodman

et al.,

1997Slide9

Prevalence of TraumaChild Mental Health/Youth Detention - US

Canadian study of 187

adolescents: 42

% had

PTSD

American study of 100 adolescent inpatients: 93% had trauma histories and 32% had

PTSD

70-90% of incarcerated girls

had experienced

sexual, physical and emotional abuse

Doc

. 1998. Chesney & Sheldon,

1991Slide10

What does this tell us?

The majority of adults and children in psychiatric treatment settings have trauma

history.

A

sizeable percentage of people with substance abuse disorders have traumatic stress symptoms that interfere with maintaining

stability.

A sizable percentage of adult and children in the prison or juvenile justice systems have trauma

histories.

Hodas

2004, Cusack et al.,

Mueser

et al.,

Lipschitz

et al, 1999, NASMHPD

1998Slide11

Therefore…

We need to presume that the clients we serve have a history

of

traumatic

stress,

and exercise “universal precautions” by creating systems of care that are

Trauma-Informed

Hodas

,

2005Slide12

Learned Response

Brain chemistry/development affected by trauma

Immediate “fight or flight” response

Heightened sense of fear/danger

Scientists have studied the brains of people who have

experienced

trauma and have noted that the ability to regulate

response

is drastically effected. They seem to always to be in a state of high alert, ready to “fight or flight” - to protect themselves from remembered harmful experiences. This is their automatic, learned response.

Our

task is to help the

person

learn new ways of responding.

Have

you ever heard the term “speechless terror,” when people are unable to speak in times of great stress? That happens when traumatic memories

shut

down the part of the brain that instigates response.Slide13

So, when we ask people in the midst of

crisis

and/or traumatic

re-enactment

to

“tell us about it,”

they

really are not able to.Slide14

Typical Trauma-related Symptoms

Dissociation

Flashbacks

Nightmares

Hyper-vigilance

Terror

Anxiety

Pejorative auditory hallucinations

Difficulty w/problem solving

Numbness

Depression

Substance abuse

Self-injury

Eating problems

Poor judgment and continued cycle of

victimization

Aggression

What we want you to understand is that these “symptoms” are not signs of pathology -

rather,

they are survival strategies that have helped them cope

with terrible pain and challenges.

The key is learn how the behavior developed and teach new coping strategies

.Slide15

Typical Trauma-related Symptoms

Triggers

are

sights, sounds, smells, and touches, that remind the person of the trauma.

Flashbacks

are recurring memories, feelings, and thoughts.

Traumatic

stress

brings the

past to the present.

The memory of the traumatizing event can trigger a response of intense fear, horror and helplessness in which extreme stress overwhelms one’s capacity to cope.

We must be aware of the negative impact that exposure to those or people, places or things can have in triggering or re-traumatizing. For example, a dark room may trigger a memory of abuse in a dark room. Just hearing a voice similar to the

abuser’s may

create a crisis situation for the child

.Slide16

Posttraumatic Stress Disorder (PTSD)

is a trauma diagnosis

Criterion A

(one required): A stressor

Criterion

B

(one required):

Intrusion symptoms

Criterion

C

(one required):

A

voidance

Criterion

D

(two

required):

Negative

alterations in cognitions and

mood

Criterion

E

(two required): A

lterations is arousal and reactivity

Criterion

F

: Duration (B, C, D, and E for more than one month)

Criterion

G

: Functional significance

Criterion

H: Exclusion (not due to meds, substance use, or other illnessIndividuals may also experience dissociative symptoms and/or delayed expression.

http://

www.ptsd.va.gov/professional/PTSD-overview/dsm5_criteria_ptsd.aspSlide17

Many of you have heard of PSTD associated with soldiers returning from combat. These folks have personally experienced and/or witnessed dreadful things.

The children we work with often have a diagnosis of PSTD.

Traumatic

events that may trigger PTSD include violent personal assaults, natural or human-caused disasters, accidents, or military combat.

We should note that family, other children and staff who witness or participate in

restraint

and

seclusion

can suffer from PTSD

.Slide18

Effects of a traumatic event may occur a few hours, several days, or a month after exposure to traumatic events, including after restraint or seclusion. Trauma symptoms

would

be present. PTSD may develop if symptoms continue

and

if left untreated.

Our

work in TIC will help alleviate the symptoms and potential of developing PTSD.Slide19

Critical Trauma Correlates

Adverse Childhood Events (ACE’s)

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,

sexually transmitted infections, cancers

Early d

eath Slide20

Adverse Childhood Experiences

Recurrent and severe physical abuse

Recurrent and severe emotional abuse

Sexual abuse

Growing up in

a household with:

An alcohol

or drug

abuser

Someone who is or had been imprisoned

Someone with a serious and persistent mental illness, chronic depression, or who is or had been institutionalized

A parent

being treated violently

Both biological parents absent

Emotional or physical abuseSlide21

http://www.acestudy.org/

The

Adverse Childhood Experiences study of the effects of trauma on future

health was

result of collaboration

of CDC

and Kaiser

Permanente.

They wanted to find out if there were any commonalities in the backgrounds of high users of

healthcare

services, chronic

illnesses,

and early deaths.

They asked participants about trauma in their childhood - about recurrent physical or emotional or sexual abuse, family substance abuse or incarceration, depression, or other mental health issues.

The study revealed the following information pictured here in this pyramid. Slide22

The more adverse/traumatic a childhood, the higher the health

risk.

Brain

development,

cognitive,

and emotional abilities are influenced by trauma. This promotes high-risk behaviors such as substance abuse and sexual

acting-out

that in turn

increase

health issues and can lead to early death.

In addition, just being in the mental health system can produce circumstances that

affect

long-term health and well-being.

The ACE Study - ResultsSlide23

Trauma-Informed Care

Recognition of prevalence of trauma

Assessment and treatment for trauma

Focus on

W

hat

happened to

you?

vs.

W

hat

is wrong with

you?

Informed by current research

Recognition that coercive environments are re-traumatizing

Universal precautions apply to

all!Slide24

Trauma-Informed Care

Recipient is center of his/her own treatment

Recipient and family are empowered

Wellness and self management are the goal

Transparent and open to outside parties

Power/control are minimized

Staff are trained and understand function of behavior

TIC respects and empowers the individual as the center of their own

wellness! Slide25

Trauma-Informed Care

The

focus is on collaboration -

Not

engaging in interactions that are demeaning, disrespectful, dominating, coercive, or controlling

Responding

to disruptive behaviors with empathy, active listening

skills,

and questions that engage the

person

in finding solutionsSlide26

Trauma-Informed Language

Person-centered

Respectful - get permission to use first name

Conscious of tone of voice and noise level

Body language

Helpful and hopeful

Objective, neutral languageSlide27

Trauma-Informed Environment

Respectful interaction

Opportunities for individual “space” and activities

Welcoming settings

Person-centered signage

In TIC, each

person

is appreciated and respected. Individuality and acknowledgement of individual

needs

is a priority.

Open communication is signaled by an atmosphere where staff are approachable.

Example: The use of

“Do Not

” signs and rules is transformed into helpful and encouraging verbiage

.Slide28

Non-Trauma-Informed

Lack of education on trauma

Over-diagnosis of schizophrenia, singular addictions, bipolar and conduct disorders

Focus is on rule enforcement and compliance

Behavior seen as intentionally provocative

Labeling:

“manipulative, needy, attention-seeking”Slide29

Problems Associated with a

Controlling Culture

Focus is on staff, not the recipient

Addressing a problem is built around staff and program convenience

Rules become more important as staff knowledge about their origin erodes

The person’s compliance

and containment are mistaken as actual learning of new skills

and/or

real improvementSlide30

Problems Associated with a

Controlling Culture

Minor violations often lead to control struggles

Fosters a belief that privileges (rights) must be earned

Reinforces a need to control the recipient

Poorly trained staff who bully

people

into compliance are not identified or disciplined

These same staff may be rewarded for maintaining safety or creating a quiet shiftSlide31

Exercise

Rephrase the following using

trauma-informed

language:

“

You need to get out of bed now!”

“You need to get in line for

lunch.”

“No, you can’t go back to your

room.”Slide32

What Happens when Traumatized People are Restrained or Secluded?

Research studies have found that

children

who were secluded:

Experienced vulnerability, neglect, shame

Repeatedly express being reminded of

their original

abuse

Express feelings of fear, rejection, anger and agitation

(

verbally and in drawings)

Wadeson

et al., 1976; Martinez, 1999; Mann et al., 1993; Ray et al.,

1996Slide33

What Happens when Traumatized People are Restrained or Secluded?

Felt they were being punished

Were confused by staff use of force

Did

not feel protected from harm

Report feelings of bitterness and anger one year later

Wadeson

et al., 1976; Martinez, 1999; Mann et al. 1993; Mohr, 1999; Ray et al.,

1996Slide34

Trauma Assessment

Purpose:

Used to identify past or current trauma, violence, and abuse, and assess related

sequelae

Provides context for current symptoms and guides clinical approaches and recovery progress

Informs the treatment culture to minimize potential for re-traumatization

Cook

et al., 2002;

Fallot

& Harris, 2002; Maine BDS,

2000Slide35

Trauma Assessment

Should minimally include:

Type: sexual, physical, or emotional abuse or neglect, exposure to disaster

Age: when the abuse occurred

Who: perpetrated the abuse

Assessment of such symptoms as: dissociation, flashbacks, hyper-vigilance, numbness, self-injury, anxiety, depression, poor school performance, conduct problems, eating problems, etc

.

Cook

et al., 2002;

Fallot

& Harris, 2002; Maine BDS, 2000Slide36

Trauma Assessment

Results

and “positive responses” must be addressed in treatment planning or assessment is useless

Interview is conducted upon intake or shortly

after

Importance of therapeutic engagement during interview cannot be over-emphasized

For children, assessment through play and behavior observations

Cook

et al., 2002;

Fallot

& Harris, 2002; Maine BDS, 2000Slide37

Core Elements in the Most Effective Treatment Programs

Memory identification, processing and regulation

Anxiety management

Identification and alteration of maladaptive cognitions

Interpersonal communication and social problem-solving

Direct intervention in the home/community

Appropriate use of medication

Hodas

,

2004Slide38

Organizational Commitment to

Trauma-Informed Care

Adoption of a trauma-informed policy to include:

Commitment

to appropriately assess trauma

Avoidance

of re-traumatizing practices

Key

administrators on board

Resources

available for system

modifications

and performance improvement

processes

Education

of staff

prioritized

Fallot

& Harris, 2002; Cook et al.,

2002Slide39

Organizational Commitment to

Trauma-Informed Care

Unit staff can access expert trauma consultation

Unit staff can access trauma-specific treatment if indicated

Fallot

& Harris, 2002; Cook et al.,

2002Slide40

Organizational Commitment to

Trauma-Informed Care

Assessment data informs treatment planning in daily clinical work

Advance directives, safety plans and de-escalation preferences are communicated and used

Power & Control are minimized by attending constantly to unit culture

Fallot

& Harris, 2002; Cook et al.,

2002Slide41

In Summary

Appreciate high prevalence rates

Understand the characteristics of trauma-informed care and how

this

differs from care that is not informed by trauma

Assess histories and symptoms of trauma and link to treatment plans/crisis plans

Provide support and skill development