Understanding Trauma and Why We Must Address It New York State Office of Mental Health March 2010.
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Transcript of Understanding Trauma and Why We Must Address It New York State Office of Mental Health March 2010.
Understanding Trauma and
Why We Must Address It
Understanding Trauma and
Why We Must Address It
New York State Office of Mental HealthMarch 2010
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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.
Objectives
Define Trauma and Trauma-Informed Care
Review Prevalence and Implications Compare Trauma-Informed and
Trauma-Insensitive Systems Identify Core Elements of
Organizational Commitment
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Trauma-Informed Care:Competency Assessment
Does More Harm Lacks Capacity Trauma-Neutral Trauma-Sensitive Trauma-Informed Trauma-Proficient
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
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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 trust
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., 1997)
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Prevalence of TraumaChild Mental Health/Youth Detention-US
Canadian study of 187 adolescents reported 42% had PTSD
American 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)
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)
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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)
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Learned Response
Brain chemistry/development affected by trauma
Immediate “fight or flight” response
Heightened sense of fear/danger
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
Triggers and Flashbacks
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.
Post Traumatic Stress Disorder (PTSD) Defined:
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 integrity
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, STDs, GYN cancer
Early Death 15
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• Mother being treated violently• Both biological parents absent• Emotional or physical abuse
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Trauma-Informed Care
Recognition of prevalence of trauma Assessment 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-traumatizing
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
Trauma-Informed CareTrauma-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 solutions
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 language
Trauma-Informed Environment
Respectful interaction Opportunities for individual
“space” and activities Welcoming settings Person-centered signage
Lack of education on trauma
Over-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-Informed
Problems Associated witha Controlling Culture
Problems Associated witha 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
Compliance and containment are mistaken as actual learning of new skills by the recipient and/or real improvement
Problems Associated witha 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 recipients into compliance are not identified or disciplined
These same staff may be rewarded for maintaining safety or creating a quiet shift
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”
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What 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)
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What 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)
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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, 2000)
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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.(Ibid)
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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(Ibid)
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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, 2004)
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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., 2002)
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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., 2002)
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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., 2002)
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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