Client-Centered and Trauma-Informed Services Deborah Werner Pat Tucker Advocates for Human Potential, Inc, This presentation is made possible with support from the Substance Abuse and Mental Health Services Administration
Nov 01, 2014
Client-Centered and Trauma-Informed Services
Deborah WernerPat Tucker
Advocates for Human Potential, Inc,
This presentation is made possible with support from the Substance Abuse and Mental Health Services Administration
The importance of a home• Place to be• Stability• Security/safety• Control• “Stuff”• Responsibility
When you don’t have these things what happens?
Homelessness is often not the first experience of trauma and
uncertainty in a homeless mother’s life.
Trauma among mothers who are homeless:
• Over their lifetime, 92% experienced severe physical and sexual assault.
• 25% experienced random violence.
• 66% experienced severe physical violence as children.
• 43% were sexually molested as children.
Bassuk EL, Weinreb L, Buckner J, et al. (1996). The characteristics and needs of sheltered homeless and low-income housed
mothers. JAMA, 276(8): 640-646.
• Emotional, sexual or physical abuse• Natural disaster/fire• Physical attack/ abuse/ threats• Life-threatening accident,
catastrophic injuries and illnesses• Witnessing injury/death• Combat• Family separation• Extremely painful and frightening
medical procedures• Rape or assault• Domestic violence
Trauma can come from many things
Photo: h.koppdelaney @ flicker.com
Accompanied by feeling of intense fear, helplessness, or horror.
Definition of TraumaThe diagnostic manual used by mental health providers (DSM IV-TR) defines trauma as, “involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one’s physical integrity; or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate.
American Psychiatric Association [APA] (2000, p 463)
Definition of Trauma (cont.)
“The person’s response to the event must involve intense fear, helplessness or horror.
…or in children, the response must involve disorganized or agitated behavior.”The
disturbance causes
clinically significant distress or
impairment in social,
occupational, or other
important areas of functioning.
American Psychiatric Association [APA] (2000, p 463)
Common Symptoms• Dissociation/freezing• Flashbacks• Hyper-vigilance• Terror• Anxiety• Self-injury• Eating problems• Sleep disturbances or
nightmares• Fight or flight response
alarm reaction followed by intense fear
• Numbing of responsiveness
• Depression• Substance abuse• Upsetting reminders and
triggers
(DSM IV(DSM IV--TR, TR, 20002000))
Photo: will fisher @ flickr.com
Trauma begins a complex pattern of
actions and reactions that have a continuing
impact over the course of one’s life.
The Impact Continues
Relationships are characterized by victim -victimizer dynamic.
Someone is the controller and someone controls.
A victim’s world view
Francine Feinberg, MetaHouse, Inc
This world view is carried through all relationships
including social services and employment.
• The world is a frightening place– Shouldn’t trust others
– Feels vulnerable
–Misreads cues– Under-reacts to real danger
– Over-reacts to innocent exchanges
The Internal Working Model
Francine Feinberg, MetaHouse, Inc
Photo: aryche @ flicker.com
• No ability to affect the situation. – Actions bring disappointment,
retribution– Hostility – Anger, Attitude– Passivity – May as well not try – Bad things will happen and no
one will protect her– Fear, anxiety– Self-protective hostility
The Internal Working Model
Francine Feinberg, MetaHouse, Inc
Photo: aryche @ flicker.com
Men React Differently to Trauma• This is an emergency!
– “Fight or flight” : men may be aggressive,
antisocial, or “on guard”
– Boys may “act out,” use substances, or be truant
• Better keep this quiet.– Boys and men are less likely to talk it
out or admit fear.
• Being a man means appearing strong.– Males may feel shame that they could
not defend themselves.
Hodas (2006), Responding to Childhood TraumaMejia (2005), Gender Matters: Working with Adult Male Survivors of Trauma
RETREAT
ISOLATIONDISSOCIATIONDEPRESSION
ANXIETY
SELF-DESTRUCTIVE ACTION
SUBSTANCE ABUSEEATING DISORDERDELIBERATE SELF-
HARMSUICIDAL ACTIONS
DESTRUCTIVEACTION
AGGRESSIONVIOLENCE
RAGES
Stephanie Covington: The Progression of Trauma
• Sense of self• Sense of efficacy• World view• Coping skills• Relationships with others• Ability to regulate emotions• How one approaches services• How one approaches the culture of the
treatment agencies, work environments, and life in general
Trauma can be self-defining
Francine Feinberg, Meta House, Inc
3 Stages of Trauma Recovery
• Safety
• Mourning
• Reconnection
Our focus today is on safety
Judith Herman
Photo: Andy and Becky’s [email protected]
• Based on current literature and informed by research and effective practice.
• Take trauma into account.
• Avoid triggering trauma reactions or retraumatization.
• Recognize the trauma of coercive interventions.
• Support the individual’s coping capability.
• Allow survivors to manage their trauma symptoms successfully so they can access, retain, and benefit from the services.
Trauma-Informed Approaches
(Fallot & Harris, 2002; Ford, 2003; Najavits, 2003)
Trauma-sensitiveservices/approaches
Trauma-insensitiveservices/approaches
• Recognition of culture and practices that retraumatize
• “Tradition of toughness”valued as best care approach
• Power/Control minimized • Keys, security uniforms, staff demeanor, tone of voice
• Caregivers/Supporters • Rule Enforcers
• Collaboration-focused • Compliance-focused
• Staff training builds awareness, sensitivity
• “Client-blaming” as fallback position without training
• Understand function of behavior such as rage, repetition-compulsion, self-injury
• Behavior seen as intentionally provocative and volitional
Trauma-Sensitive vs. Trauma-Insensitive Approaches
(Fallot & Harris, 2002; Cook et al., 2002; Ford, 2003; Cusack et al., 2004; Jennings, 1998; Prescott, 2000)
Trauma-sensitiveworkers
Trauma-insensitiveworkers
• Objective, neutral language • Labeling language: manipulative, needy, gamey, “attention-seeking”
• “Let’s talk and find you something to do that will help.”
• “If I have to tell you one more time ….”
• Focus is on person – eye contact • Focus on task, not person• Says hello and goodbye • Comes and leaves with little
acknowledgement
Trauma-Sensitive vs. Trauma-Insensitive Workers
(Fallot & Harris, 2002; Cook et al., 2002; Ford, 2003; Cusack et al., 2004; Jennings, 1998; Prescott, 2000)
• Understanding Triggers
• Building Trusting Relationships
• Emphasize Strengths
• Building Coping Skills
• Children and Families
Client-Centered, Trauma-Informed Approaches
What is a Trigger?• A trigger is a
troubling reminder of a traumatic event.
• The trigger itself need not be frightening or traumatic.
• It can be conscious or unconscious.
• Triggers are often subtle and difficult to anticipate.
Adapted from Fagan, Nancy; Kathleen Freme. 2004
Photo: [email protected]
Some things that may be triggering
• Individual people
• Places
• Emotions
• Noises
• Images
• Smells
• Tastes
• Color
• Environmental conditions
• Animals
• Films or scenes within films
• Dates of the year
• Tones of voice
• Body positions
• Bodily sensations
• Weather conditions
• Time factors
Discussion• What are some environmental factors
in your agencies or groups that may trigger someone who has experienced trauma?
• What may happen when an individual who has experienced trauma is triggered?
• What can you do to prevent or minimize crises?
• See the family/believe in them• Take the time• Start where they are• See the possibility• Demonstrate compassion• Share hope• Avoid judging• Be responsive to immediate needs• Show respect• Do what you say you will do
Building Trust
Hope
Everything we do and say should be infused with the hope and belief that people’s lives change, people get better, and recovery is possible!
Tips for Trauma-Sensitive Relationships
• Be aware, mindful, respectful
• Don’t probe – let the person raise the issues
• Avoid judging or labeling behaviors as manipulation
• Maintain strengths-based view• Work through resistance: What
is the person trying to tell us?
Photo: [email protected]
See the Strengths• As an individual
• As a family
• As a family member
• As a parent
• In the environment
Discovering Strengths
• Patterns• Attitudes• Coping styles• Values – family, cultural,
social• Choice• Personality characteristics• Environmental – home,
community, resources• Beliefs• Feelings – emotions• Knowledge – intelligence
• Talents – hobbies• Stamina• Common sense• Relationships• Interests – desires• Physical attributes, health• Behavior – skills• Things person does well• Achievements• Flexibility• Resourcefulness
There are many ways to see strengths of an individual or family, including:
Sometimes we think our clients should do one thing and they choose to do another.
They may have different priorities.
They may make mistakes.
Either way, they are the decision-makers.
Self Determination
People make choices all the time about treatment programs, but it may look to us like non-compliance! Using self-determination as a principle of case management means to recognize this fact and use it to create “buy-in” for a treatment plan.
Exercise• In pairs – one person is the staff
member and one a homeless woman. The homeless woman wants the candy and the staff member wants her to have the carrot.
• What happened. What did the case manager do? How did the woman feel? What is the long-term impacts?
Key Questions• Where are you now?
• Where do you want to be?
• What resources do you have available to help you get there?
• What can we do together to help you get where you want to be?
Planning Tips
• Remember, it’s not your decision. Help others set goals and prioritize.
• Focus on concrete steps
• Find and offer practical tools
• Don’t be afraid to change horses
• Focus on positive action
• Coordinate and collaborate
Building Skills• Coping Skills
• Responding instead of Reacting
• Life Skills
• Communication
• Parenting (trauma-informed)
Always ask – is it practical? Does if fit with the family goals? Make it real!
celebrate successes!
Life on Life’s Terms
Take it easy!
People who are surviving on the streets and in shelters are just that – survivors! You don’t have to meet every need immediately, and they can’t or won’t work on recovery full time.
• Client problems evoke sympathy and vulnerability, which may lead to excessive support and overindulgence rather than encouraging client accountability and growth.
• Client struggles can trigger staff frustration, harsh judgments, and punitive confrontations.
Worker ReactionsWorkers may unwittingly repeat client
trauma roles: victim, perpetrator, bystander.
The Life Balance Wheel
Is your life in balance?
Add spokes to the wheel to represent
your self‐care activities in each
area.
Examples of Trauma Programs• Amaro, H., & Nieves, R. L. (2009). Boston Consortium Model:
Trauma-Informed Substance Abuse Treatment for Women. Contact: Hortensia Amaro at [email protected] or Rita Nieves [email protected].
• Clark, C., Fearday, F. (eds) (2003) Triad Women’s Project: Group facilitators manual. Tampa, FL: Louis de la Parte Florida Mental Health Institute, University of South Florida. (contact Colleen Clark at [email protected])
• Covington , S. S. (2003) Beyond Trauma: A Healing Journey for Women. Center City, MN: Hazelton Press. (Contact Stephanie Covington at [email protected])
Examples of Trauma Programs (continued)
• Ford, J.D., Mahoney, K., Russo, E., Kasimer, N., & MacDonald, M. (2003). Trauma Adaptive Recovery Group Education and Therapy (TARGET): Revised Composite 9-Session Leader and Participant Guide. Farmington, CT: University of Connecticut Health Center. (Contact Julian Ford at [email protected] )
• Harris, M. (1998). Trauma, Recovery and Empowerment: A Clinician’s Guide for Working with Women in Groups. New York, NY: Free Press. (Contact Rebecca Wolfon Berley at [email protected])
• Miller, D., & Guidry, L. ( 2001). Addictions and Trauma Recovery: Healing the Mind, Body, and Spirit. New York: W.W. Norton. (Contact Dusty Miller at [email protected])
• Najavits, L. (2001). Seeking Safety: Cognitive-Behavioral Therapy for PTSD and Substance Abuse. New York: Guilford. (Go to www.seekingsafety.org)
• Saakvitne, K. W., Gamble, S.J., Pearlman, L.A., Lev, B.T. (2000). Risking Connection: A Training Curriculum for Working with Survivors of Childhood Abuse. Maryland: Sidran. (Go to www.sidran.org)
Michael W. Smith
Transformation in the world
happens when people are healed
and start investing in other
people.
Thank YouThis presentation has been developed and presented
by Advocates for Human Potential, Inc. with support
by the Substance Abuse and Mental Health Services
Administration
Deborah Werner, MA – [email protected] Tucker, MA, MBA – [email protected]