1 By David Fuller, CPRP Florida Partners in Crisis 2011 Annual Conference and Justice Institute “Leading Change, Inspiring Innovation” TRAUMA and RECOVERY:

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By David Fuller, CPRPFlorida Partners in Crisis 2011 Annual Conference and Justice

Institute “Leading Change, Inspiring Innovation”

TRAUMA and RECOVERY: A SELFHELP APPROACH

CONSUMER LEADERSHIP IN THE SUPPORT OF PEOPLE RECOVERING

FROM TRAUMA

Presenter

David Fuller, CPRPForensic Peer Services Coordinator, New York Association of Psychiatric

Rehabilitation

As an administrator, service provider, and independent consultant, Mr. Fuller is an agent of change, and draws on personal experience as a consumer—and the opportunity to overcome many challenges— to fuel his mission of improving access to services for people who have been affected by psychiatric diagnoses, substance abuse and use the public mental health system; for this reason he was called before the United States Senate Sub Committee on Human Rights to testify on the subject of incarceration and mental illness.

David has been a guest lecturer at the Columbia, NYU, Hunter, and Adelphi Schools of Social Work on Trauma and Recovery.

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What is Trauma and Why Must We Address It?

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What is Trauma?What is Trauma?

• Definition Definition ((NASMHPDNASMHPD, , 20062006))

– The experience of violence and victimization including The experience of violence and victimization including sexual abuse, physical abuse, severe neglect, loss, domestic sexual abuse, physical abuse, severe neglect, loss, domestic violence and/or the witnessing of violence, terrorism or violence and/or the witnessing of violence, terrorism or disastersdisasters

• DSM IV-TR DSM IV-TR ((APAAPA, , 20002000))

– Person’s response involves intense fear, horror and Person’s response involves intense fear, horror and helplessnesshelplessness

– Extreme stress that overwhelms the person’s capacity to Extreme stress that overwhelms the person’s capacity to copecope

What is Trauma

Events/experiences that are shocking, terrifying, and/or overwhelming to the individual.

Results in feelings of fear, horror, helplessnessTriggering events may include witnessing, sensory

exposure, media exposureWhat types of events are traumatic?

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What is Trauma

Pre and Perinatal TraumaPre and Perinatal Trauma

Single Episode TraumaSingle Episode Trauma

Developmental or Complex TraumaDevelopmental or Complex TraumaHistorical TraumaHistorical Trauma

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Types of Trauma Resulting in Serious Mental Illness

• Are usually not a “single blow” event e.g. rape, natural disaster

• Are interpersonal in nature: intentional, prolonged, repeated, severe

• Occur in childhood and adolescence and may extend over an individual’s life span

(Terr, 1991; Giller, 1999)

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What does trauma do?

Trauma changes the way people perceive reality.

Trauma shapes a child’s basic beliefs about identity, world view, and spirituality.

Using a trauma framework, the effects of trauma can be addressed and a person can go on to lead a “normal” life.

Symptoms are ADAPTATIONS

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Definition of TraumaDefinition of TraumaInformed CareInformed Care

Mental Health Treatment that incorporates:Mental Health Treatment that incorporates:– An appreciation for the high prevalence of traumatic An appreciation for the high prevalence of traumatic

experiences in persons who receive mental health servicesexperiences in persons who receive mental health services

– A thorough understanding of the profound neurological, A thorough understanding of the profound neurological, biological, psychological and social effects of trauma and biological, psychological and social effects of trauma and violence on the individualviolence on the individual

((Jennings, 2004Jennings, 2004))

Prevalence of TraumaMental Health Population

90% of public mental health clients have been exposed (Muesar et al., in press; Muesar et al., 1998)

Most have multiple experiences of trauma

34-53% report childhood sexual or physical abuse (Kessler et al., 1995; MHA NY & NYOMH, 1995)

43-81% report some type of victimization

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Prevalence of TraumaMental Health Population – Adults

Study in South Carolina CMHC found 91% of clients had histories of trauma (Cusack, Frueh & Brady, 2004)

97% of homeless women with SMI have experienced severe physical & sexual abuse – 87% experience this abuse both in childhood and adulthood (Goodman et al, 1997)

Majority of adults diagnosed BPD (81%) or DID (90%) were sexually or physically abused as children

(Herman et al, 1989; Ross et al, 1990)

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Prevalence of TraumaPrevalence of TraumaChild Mental Health/Youth Detention Population - U.S.Child Mental Health/Youth Detention Population - U.S.

• Canadian study of 187 adolescents reported 42% Canadian study of 187 adolescents reported 42% had PTSDhad PTSD

• American study of 100 adolescent inpatients; 93% American study of 100 adolescent inpatients; 93% had trauma histories and 32% had PTSDhad trauma histories and 32% had PTSD

• 70-90% incarcerated girls – sexual, physical, 70-90% incarcerated girls – sexual, physical, emotional abuse emotional abuse

((DOC, 1998, Chesney & Sheldon, 1991DOC, 1998, Chesney & Sheldon, 1991))

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Prevalence of TraumaPrevalence of TraumaSubstance Abuse Population – U.S.Substance Abuse Population – U.S.

• Up to two-thirds of men and women in SA treatment report childhood abuse & neglect

(SAMSHA CSAT, 2000)

• Study of male veterans in SA inpatient unit– 77% exposed to severe childhood trauma– 58% history of lifetime PTSD (Triffleman et al., 1995)

• 50% of women in SA treatment have history of rape or incest (Governor's Commission on Sexual and Domestic Violence, Commonwealth of MA, 2006)

Sexual Trauma and Addiction

208 African-American Women with histories of crack cocaine use

Women with history of sexual trauma (n=134) reported being addicted to more substances than those who had not been sexually traumatized (n=74)

Women with trauma histories reported more prior treatment failures than those without.

(Young & Boyd, 2000)

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What does the prevalence data mean?

• The majority of adults and children in psychiatric treatment settings have trauma histories as do children and adults served in a variety of 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)

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Other Critical Trauma Correlates: Other Critical Trauma Correlates: The The Relationship of Childhood Trauma to Adult HealthRelationship of Childhood Trauma to Adult Health

Adverse Childhood Events (ACEs) have serious Adverse Childhood Events (ACEs) have serious health consequences health consequences

• Adoption of health risk behaviors as coping Adoption of health risk behaviors as coping mechanisms: mechanisms: eating disorders, smoking, substance eating disorders, smoking, substance abuse, self harm, sexual promiscuityabuse, self harm, sexual promiscuity

• Severe medical conditions: Severe medical conditions: heart disease, pulmonary heart disease, pulmonary disease, liver disease, STDs, GYN cancerdisease, liver disease, STDs, GYN cancer

• Early DeathEarly Death (Felitti et al., 1998)

Adverse Childhood Experiences Study

The Adverse Childhood Experiences (ACE) Study. ACE is a decade-long and ongoing collaboration between Kaiser Permanente’s Department of Preventive Medicine in San Diego and the Centers for Disease Control and Prevention

(CDC). The ACE study was designed to assess the relationship between the childhood experiences and the current health status and health risk behaviors of 30,000 mainly middle-class adult members of Kaiser Permanente. To date, data have been collected from 19,000 cooperating adults.

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Adverse Childhood Experiences Study

The study indicates that childhood abuse and household dysfunction lead to the development—decades later—of the chronic diseases that are the most common causes of death and disability in this country, including heart disease, cancer, stroke, diabetes, skeletal fractures, chronic lung disease, and liver disease. A strong relationship is shown between the number of adverse childhood experiences and reports of cigarette smoking, obesity, physical inactivity, alcoholism, drug abuse, depression, suicide attempts, sexual promiscuity, and sexually transmitted diseases.

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Adverse Childhood Experiences Study

Furthermore, persons who reported higher numbers of adverse childhood experiences were much more likely to have multiple health risk behaviors. Similarly, the more adverse childhood experiences reported, the more likely the person was to develop chronic and disabling illnesses. Traditionally viewed as public health or mental health problems, these behaviors appear to be coping mechanisms for people who have had adverse childhood experiences, the study found. Authors suggest the behaviors may also reflect the effects of the adverse experiences on the developing brain chemistry—effects that may lead to the adoption of the coping behaviors (www.acestudy.org).

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Adverse Childhood ExperiencesAdverse Childhood Experiences

– Recurrent and severe physical abuseRecurrent and severe physical abuse– Recurrent and severe emotional abuseRecurrent and severe emotional abuse– Sexual abuseSexual abuse

• Growing up in household with:Growing up in household with:– Alcohol or drug userAlcohol or drug user– Member being imprisonedMember being imprisoned– Mentally ill, chronically depressed, or institutionalized Mentally ill, chronically depressed, or institutionalized

membermember– Mother being treated violentlyMother being treated violently– Both biological parents absentBoth biological parents absent– Emotional or physical abuseEmotional or physical abuse

((FellittiFellitti et al, 1998et al, 1998))

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ACE StudyACE Study

• ““Male child with an ACE score of 6 has a 4600% Male child with an ACE score of 6 has a 4600% increase in likelihood of later becoming an IV drug increase in likelihood of later becoming an IV drug user when compared to a male child with an ACE user when compared to a male child with an ACE score of 0. Might heroin be used for the relief of score of 0. Might heroin be used for the relief of profound anguish dating back to childhood profound anguish dating back to childhood experiences? Might it be the best coping device that experiences? Might it be the best coping device that an individual can find?”an individual can find?”

((Felitti et al,Felitti et al, 1998) 1998)

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ACE StudyACE Study

• Is drug abuse self-destructive or is it a Is drug abuse self-destructive or is it a desperate attempt at self-healing, albeit desperate attempt at self-healing, albeit while accepting a significant future while accepting a significant future risk?”risk?”

(Felitti, et al, 1998)(Felitti, et al, 1998)

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ACE StudyACE Study

• “ “ Addiction is best viewed as an Addiction is best viewed as an understandable, unconscious, compulsive understandable, unconscious, compulsive use of psychoactive materials in response use of psychoactive materials in response to abnormal, prior life experiences, most of to abnormal, prior life experiences, most of which are concealed by shame, secrecy, which are concealed by shame, secrecy, and social taboo.”and social taboo.”

((Felitti et al, 1998Felitti et al, 1998))

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What does the prevalence data tell us?What does the prevalence data tell us?

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

• A sizable percentage of people with substance use A sizable percentage of people with substance use disorders have traumatic stress symptoms that disorders have traumatic stress symptoms that interfere with achieving or maintaining sobrietyinterfere with achieving or maintaining sobriety

• A sizable percentage of adults and children in the A sizable percentage of adults and children in the prison or juvenile justice system have trauma prison or juvenile justice system have trauma historieshistories

(Hodas, 2004, Cusack et al., Mueser et al., 1998, Lipschitz et al., 1999, NASMHPD, 1998)

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What does the prevalence data What does the prevalence data tell us?tell us?

• Growing body of research on the relationship Growing body of research on the relationship between victimization and later offendingbetween victimization and later offending

• Many people with trauma histories have Many people with trauma histories have overlapping problems with mental health, overlapping problems with mental health, addictions, physical health, and are victims or addictions, physical health, and are victims or perpetrators of crimeperpetrators of crime

• Victims of trauma are found across all systems Victims of trauma are found across all systems of careof care

(Hodas, 2004, Cusack et al., Muesar et al., 1998, Lipschitz et al., 1999, NASMHPD, 1998)

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Therefore……Therefore……

We need to presume the clients we We need to presume the clients we serve have a history of traumatic serve have a history of traumatic stress and exercise “universal stress and exercise “universal precautions” by creating systems precautions” by creating systems of care that are of care that are trauma-informedtrauma-informed

((HodasHodas, , 20052005))

What you’ll see in Participants/Clients

Aggression and low impulse control in new situations or with new people

Power struggles and fear in the context of rule enforcement

Disengagement as means of defenseInterpretation of safety enforcement as

predatory“Minor” events precipitating catastrophic

reactions

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What you will see in Treatment Providers

• Often have their own traumatic histories, including historical trauma

• Seek to avoid re-experiencing their own emotions

• Respond personally to others’ emotional states• Perceive behavior as personal threat or

provocation rather than as re-enactment• Perceive client’s simultaneous need for and fear

of closeness as a trigger of their own loss, rejection, and anger

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Trauma InformedTrauma Informed Non Trauma InformedNon Trauma Informed• Recognition of high Recognition of high

prevalence of traumaprevalence of trauma• Recognition of Recognition of

primary and co-primary and co-occurring trauma occurring trauma diagnosesdiagnoses

• Assess for traumatic Assess for traumatic histories & symptomshistories & symptoms

• Recognition of Recognition of culture and practices culture and practices that are re-that are re-traumatizingtraumatizing

• Lack of education on Lack of education on trauma prevalence & trauma prevalence & “universal” precautions“universal” precautions

• Over-diagnosis of Over-diagnosis of Schizophrenia & Bipolar Schizophrenia & Bipolar D., Conduct D. & D., Conduct D. & singular addictionssingular addictions

• Cursory or no trauma Cursory or no trauma assessmentassessment

• ““Tradition of Toughness” Tradition of Toughness” valued as best care valued as best care approachapproach

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Trauma InformedTrauma Informed Non Trauma InformedNon Trauma Informed

• Power/control Power/control minimized - constant minimized - constant attention to cultureattention to culture

• Caregivers/supporters Caregivers/supporters –– c collaborationollaboration

• Address training Address training needs of staff to needs of staff to improve knowledge & improve knowledge & sensitivitysensitivity

• Keys, security uniforms, Keys, security uniforms, staff demeanor, tone of staff demeanor, tone of voicevoice

• Rule enforcers –Rule enforcers – ccomplianceompliance

• ““Patient-blaming” as Patient-blaming” as fallbackfallback position without position without trainingtraining

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Trauma InformedTrauma Informed Non Trauma InformedNon Trauma Informed

• Staff understand function Staff understand function of behavior (rage, of behavior (rage, repetition-compulsion, repetition-compulsion, self-injury)self-injury)

• Objective, neutral Objective, neutral languagelanguage

• Transparent systems Transparent systems open to outside partiesopen to outside parties

• Behavior seen as Behavior seen as intentionally provocativeintentionally provocative

• Labeling language: Labeling language: manipulative, needy, manipulative, needy, “attention-seeking”“attention-seeking”

• Closed system – Closed system – advocates discouragedadvocates discouraged

(Fallout & Harris, 2002; Cook et al., 2002, Ford, 2003, Cusack et al., Jennings, 1998, Prescott, 2000)

TRAUMA INFORMED PRACTICE VS. TRADITIONAL APPROACH

Trauma-Informed

Collaborative relationship

Integrated whole person view of individual and context(complexity of people’s lives)

“Symptoms” are seen as coping strategies (ACE Study)

Primary goals are empowerment, recovery, and self-determination (building on strengths, expertise of lived experience)

Traditional

Hierarchical relationship

Each system has its own view of the person and his/her “problems”

Problems and symptoms are synonymous

Primary goals are stability and absence of symptoms

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FOCUS ON TRAUMA INFORMED PRACTICE

Commitment and involvement from top leadership (Champions) with a consistent message.

Identification of a person/group responsible for ongoing training and education of the staff and participants (Champions) (participant’s trauma-informed bill of rights)

Part of supervision structure One can’t give what they are not getting Principles and practice of trauma-informed

apply across the agency (at all levels, from the receptionist to the Board of Directors)

Part of agency plan (long-term commitment)

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TRAUMA INFORMED PRACTICE

Includes understanding of prevalence, impact, and recovery

Belief that recovery is possible for all

Understands intergenerational aspect of trauma

Focuses on “what happened” not “what’s wrong”

Based on understanding of healing relationships (healing happens in relationships)

Seeks to eliminate re-victimization and re-traumatization

Speaks to voice, choice, and control

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Trauma and Recovery

A Peer Support Approach Utilizing Rational Emotive Behavioral Therapy

Methods

What Is Needed?

One Peer trained in the modelOther peers who want to participateA place to meetManual and supporting literature (Books by

Albert Ellis)The ability to identify feelings or have the

desire to learn.Commitment

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Trauma and Recovery

Trauma profoundly changes the way we perceive and experience life.

One out of two American Adults experience at least one traumatic event in their life.

People with co-occurring mental health and substance abuse disorders it is almost a universal truth.

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Trauma and Recovery

Some examples of Trauma are: Physical, Sexual, and Emotional Abuse;

Violence, War, Homelessness, Severe Substance Abuse, Incarceration, Restraint, Seclusion, Poverty, Discrimination, Natural Disaster etc..

“You would be surprised at what human beings can adapt to!” Or Do They?

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Trauma and Recovery

Trauma responses are attitudes andbehaviors that helped people to

survivetheir experiences.(hypervigilence,“antisocial behavior”)Mental illness, substance abuseCriminalityRational decision making has “left

the building”

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Trauma and Recovery

Emotions are almost always in control.“Avoid further pain at all costs”

SO WHAT FINALLY HELPED!

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Trauma and Recovery

• Peer Support which is an evidence based practice combined with R.E.B.T. which is one of the original forms of modern CBT developed by Dr. Albert Ellis

• As the word “rational” implies we will be changing our thinking using facts to diminish negative beliefs and feelings

• We do this by using the “ABC Paradigm”

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Trauma and Recovery

A) is the activating eventB) is the belief/negative self-statement

(irrational)C) negative emotional consequencesD) combat with new positive/rational self-

statementE) new/diminished feelings

Absolute Statements

Usually the negative statements that cause our unwanted negative emotional consequences contain words that that do not leave room for compromise.

If we can identify these words in our self-statements we can then begin to empower ourselves to take some real control over our emotional state

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IRRATIONALIRRATIONAL RATIONALRATIONAL

A) Someone moves in front of me during rush hour traffic

B)“People always cut me off in traffic!”

C) Frustration, Anger

D) Sometimes people need to get in front of me to get where they are going.

E) annoyed, maybe understanding

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UncompromisingUncompromising CompromisingCompromising

Can’tWon’tNeverAlwaysAllEvery timeEveryoneTotally

SometimesOccasionallySome A FewFrom time to timeOnce in awhileMaybe

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Trauma and Recovery

Most “therapies” goal is to make the person feel better but it does not fix the problem.

REBT taught by a Credible Role Model (PEER Support) teaches a person a concrete skill that they can use to attempt to change the way they think and behave. It takes action on the part of the participant which encourages empowerment.

Trauma and Recovery

“Emotional Literacy”The ability to “read and comprehend”

yourselfTo make sense of our “inner space” we need

to be able to attach words to our feelings so that we can communicate our needs to others, and understand ourselves

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Trauma and Recovery

THINGS TO REMEMBER:Trauma changes the way you perceive lifeThe focus is safety and avoiding pain, not

being rationalWomen are usually looking to be

empowered, Men are usually looking for permission to express their feelings

You must start asking people what happened to them? Not what is wrong with them.

RESOURCES

The Essence of Rational Emotive Behavior Therapy, by Albert Ellis, Ph.D. Revised, May 1994.)

www.stopstigma.samhsa.gov/archtelpdf/PeerSupport_Presentation.ppt

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Trauma and Recovery

For further questions please contact:

David Fuller, [email protected]

NYAPRS1 Columbia PlaceAlbany, NY 12207