Understanding Trauma and - PowerPoint Presentation

Slide1

Understanding Trauma and Why We Must Address It

New York State Office of Mental Health

March 2010Slide2

2Acknowledgement

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.Slide3

ObjectivesDefine Trauma and Trauma-Informed CareReview Prevalence and Implications

Compare

Trauma-Informed

and

Trauma-Insensitive

Systems

Identify Core Elements of Organizational Commitment

3Slide4

4Trauma-Informed Care:

Competency Assessment

Does

More Harm

Lacks

Capacity

Trauma-Neutral

Trauma-Sensitive

Trauma-Informed

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 IV-TR (APA 2000)

- Person’s response involves intense fear, horror, and helplessness

- Extreme stress that overwhelms ability to cope

5Slide6

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

A severe one time, or repeated event

Actions perpetrated by someone known

Acts that betray trustSlide7

Prevalence of TraumaMental Health Population-US90% 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., 1997)

7Slide8

Prevalence of TraumaChild Mental Health/Youth Detention-USCanadian study of 187 adolescents reported 42% had PTSDAmerican study of 100 adolescent inpatients: 93

% had trauma histories and 32% had PTSD

70-90% of incarcerated

girls - sexual

, physical and emotional abuse

(Doc. 1998. Chesney & Sheldon, 1991)Slide9

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 1998)

9Slide10

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

, 2005)

10Slide11

Learned ResponseBrain chemistry/development affected by traumaImmediate “fight or flight” response

Heightened sense of fear/dangerSlide12

Typical Trauma-related SymptomsDissociationFlashbacks

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

Slide13

Triggers and FlashbacksTriggers 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.Slide14

Post Traumatic Stress Disorder (PTSD) Defined: The development of characteristic symptoms, following exposure to a traumatic stressor involving direct personal experience or witnessing another person’s experience of:

Actual or threatened death

Actual or threatened serious injury

Threat to physical integritySlide15

Critical Trauma CorrelatesAdverse Childhood Events (ACE’s) have serious health consequencesAdoption 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

15Slide16

Adverse Childhood ExperiencesRecurrent and severe physical abuseRecurrent and severe emotional abuseSexual abuse

Growing up in household with:

Alcohol or drug user

Member being imprisoned

Mentally ill, chronically depressed, or

institutionalized

member

Mother being treated violently

Both biological parents absent

Emotional or physical abuse

16Slide17

17 Slide18

Trauma-Informed CareRecognition of prevalence of traumaAssessment and treatment for trauma

Focus on what happened to you vs. what is wrong with you

Informed by current research

Recognition that coercive environments are re-traumatizingSlide19

Trauma-Informed CareRecipient is center of his/her own treatmentRecipient

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 behaviorSlide20

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 recipient in finding solutionsSlide21

Trauma-Informed LanguagePerson centeredRespectful - get permission to use first name

Conscious of tone of voice and noise level

Body language

Helpful and hopeful

Objective, neutral languageSlide22

Trauma-Informed Environment

Respectful interaction

Opportunities for individual “space” and

activities

Welcoming settings

Person-centered

signage Slide23

Lack of education on traumaOver-diagnosis of schizophrenia, singular addictions, bipolar and conduct disorders Rule enforcement/compliance focus

Behavior seen as intentionally provocative

Labeling: “manipulative, needy, attention-seeking

”

Non-Trauma-InformedSlide24

Problems Associated witha Controlling CultureFocus 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

Compliance and containment are mistaken as actual learning of new skills by the recipient and/or real improvementSlide25

Problems Associated witha Controlling CultureMinor 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 recipients into compliance are not identified or disciplined

These same staff may be rewarded for maintaining safety or creating a quiet shiftSlide26

ExerciseRephrase 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”Slide27

27What Happens when Traumatized Consumers are Restrained or Secluded?

Research studies have found that

children who were secluded:

Experienced vulnerability, neglect, shame

Repeatedly express being reminded of 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., 1996)Slide28

28What Happens when Traumatized Consumers are Restrained or Secluded?Felt they were being punished

Were confused by staff use of force

Do 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., 1996)Slide29

29Trauma AssessmentPurpose

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, 2000)Slide30

30Trauma AssessmentShould 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.

(Ibid)

Slide31

31Trauma AssessmentResults 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

(Ibid)

Slide32

32Core 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

, 2004)Slide33

33Organizational 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., 2002)Slide34

34Organizational 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., 2002)Slide35

35Organizational Commitment to Trauma Informed CareAssessment 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., 2002)Slide36

36In 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