A brief overview of trauma informed care

A BRIEF OVERVIEW OF TRAUMA INFORMED CARE And how it may look through Family Support Services at MFS

Main messages…..

Most (if not all) of our clients have been exposed to trauma. Trauma-informed care is a way of integrating an awareness

of the impact of trauma with existing practice. Trauma-informed care is NOT therapy, theory or

intervention. It is a way to understanding those we serve. Trauma-informed care is not about doing extra work. It is

about looking through the lenses of trauma while doing the things we already know in our work, but adding this perspective. Much like empowerment lens/perspective.

This perspective can be added to every interaction and intervention in those seeking care.

Adverse Childhood Experiences Study (ACES)

ACES contribute to Disease and medical cost Depression and suicide Alcoholism and drug use Job performance problems and disability Multi-generational problems Genetically transmitted over time (not

conclusive data)

SOCIAL DETERMINANTS OF HEALTH?

Persistent Fear StatePsychology and Physiology of Trauma

Traumatic Event

Prolonged alarm

reaction

Altered neural systems

Psychological Universal Precautions

GLOVE UP!!

Presume that every person in your system of care has been exposed

to abuse, violence, neglect or other traumatic experiences.

Nicole……

Identify any immediate needs that Nicole may have.

Identify the crucial childhood issues for Nicole

Identify your main concerns related to being able to help Nicole and provide her with emotional support.

HOW does this look in your role at MFS?

Resiliency Factors

Intelligence Temperament Quality of Relationships Determination Optimism Sense of meaning and purpose in life Caring for self/awareness of needs Accepting help from others Ability to access positive social support following the

traumatic events

Resiliency is not a FIXED trait.

How Trauma Hurts

Feelings (Self Capacities) Inner connection to positive others Sense of self as deserving life, love, and

kindness Ability to manage emotions*Judgment*Beliefs*Frame of Reference*Memory and Perception*Body and Brain

Feelings (Self Capacities)

Inner connection to positive others

Sense of self as deserving life, love and kindness

Ability to manage emotions

What was it you were trying to

achieve?

How do you help strengthen attachments?

Basis of your intervention

If trauma is not external there are one or more unmanageable emotions

Typical Trauma Responses

Depression Withdrawal Sleep disturbance Clinging Acting like nothing happened Emotional reactivity Irritability, angry outbursts Heightened anxiety

Serious Responses

Self-harming behavior Substance Abuse Eating disorders Dangerous sexual practicesIdentity DisturbanceEnduring or escalating aggressionMutismAmnesia related to own behavior

Dilemmas

Not seen as credible Treated by society as invisible

The effects of trauma, by their very nature, can make relationships very

difficult for the survivor and supporters alike.

What we can do now?

Routinely seek history of adverse childhood experiences (ACES) from all clients. Witnessing a traumatic event can be as

damaging as experiencing them. Acknowledge their reality by asking “How has

this affected you later in life”? Develop systems to help with current

problems Develop systems for early prevention.

THINK: What happened to this person? Instead of What is wrong with this person?

Features of Trauma Informed Care Organizations

Valuing the individual in all aspects of care Neutral, objective and supportive language Individually flexible plans and approaches Avoid shaming or humiliation at all times Awareness/training on re-traumatizing

practices Institutions that are open to outside parties:

advocacy and clinical consultants Training and supervision in assessment and

treatment of people with trauma histories

Continued…

Focusing on “what happened to you vs what is wrong with you”

Asking questions about current abuse Addressing the current risk and developing

a safety planOne person sensitively asking questions

It’s all about attachment

“Secure attachment is the anecdote for trauma”

(Joan Allen, 1995, p. 39)

Why it’s important to view problematic behaviors as adaptations? Strength-based, not deficit-based Assist the helper to not take a survivor's

negative behaviors personally Reduces shame and blame-survivors

come in expecting to be blamed Helper is allied with client to solve a

problem together Assumes, at any moment, survivor doing

the best s/he can

A RICH relationship

These four components define a relationship that is growth-promoting, not matter its duration:

*Respect-make no assumptions

*Information-give and take

*Connection- Be real

*Hope- Cultivate yours

It is NOT the technique it’s the attention paid by the helper that is the best predictor of outcome.

Why is a RICH relationship important?

Creates connectedness and attachment Decreases shame and isolation Promotes change and healing Contradicts basic assumptions about self

and the world Separates past experiences from present

experiences

How does this align?

To move people beyond the limitations of poverty, inequity and social isolation

Revisit Nicole…..

While taking note of the self-capacities discussed earlier apply these to Nicole….

What did you learn about your concerns and goals for Nicole?

Stress Response

Stress Reactions Fight Flight Freeze Gather and ProtectFunctions? To return to a balanced stateTwo means to that end:

Dissociation-splitting off…to disassociate from threatHyper arousal-Super aware…at attempt to make the unpredictable predictable

Trauma Toolboxes

Grounding Orienting and comforting the child

Toys, blankets, music, snacks-creature comforts

Expressive Activities Drawing, writing, story telling, music, play

Imagery Gauges, regulators, and containers Soothing images, beach, fantasy voyages

Toolboxes contd

Narrative activitiesWhat happened? What are you thinking? Feeling?

Reassuring an anticipatingcalming anxieties and fears

SleepPreparing them for sleepSettling and soothing

Kids benefit from having a physical connection with a feeling or event which is why puppets, art and other hands on activities are therapeutic.

**Breathing in a painful color and blowing it out**

BASKI—How grounding connects

B

A

S

K

I

ehavior

ffectensationnowledge

magination…takes over. What leads you to panic?

The Slippery Slope

EVENT

THOUGHT

FEELING

IMPULSE

BEHAVIOR

DISSOCIATIONSUICIDALITYSELF HARMSUBSTANCE ABUSEEATING DISORDER

So what?

Behavior is about solving the feeling, not the problem

Behavior becomes a new event

Identify Support

What are your resources Internal

Self-respect Determination Faith

External Friends, family, therapist, clergy Meetings Nature

Make a Plan

Acknowledge and list triggers or risk factors

Identify points of intervention Identify interventions that work Practice, practice, practice

Transference & Projection

Transference Transferring feelings from a pat relationship

to a present one

Projectionprojecting one’s own feelings onto

someone elseWith survivors, what gets transferred and projected onto the helper is likely to be

negative. This is normal given survivors’ past experiences and current beliefs

Developmental Model of Practice

Do for you

Do it with you

Stand by and admire

What is countertransference The feelings, thoughts, and physical

responses a helper has to a victim/survivor

The helper’s defenses and responses to the uncomfortable feelings brought up by the victim/survivor

Countertransference is a normal part of our work

How is this person received in the world? That’s all we need to know.

Benefits

When you experience the victim’s feelings instead of the victim feeling them

Gives you important information about the survivor

When your feelings seem to be like those the victim felt or important people in the victim’s life experienced in the past

Increases your empathy and understanding

Problematic

Interferes with the helper’s understanding of the victim/survivor, or

Prevents the helper from responding in an appropriate therapeutic way to the victim/survivor’s needs

Empathy and the shadow voice

Giving empathy to your own transference allows you to give empathy toward a client

who you may be having *countertransference with

*strong feelings about*difficulty connecting with

Projective Identification

Client unconsciously disowns intolerable emotions

Those emotions are felt by the clinician and mistaken for his/her own feelings.

If unrecognized, leaves helpers feeling very confused.

Common Projective Identifications

WHEN YOU EXHIBIT EMOTIONS AROUND WHAT A CLIENT SHARED BUT A CLIENT SHOWS NO EMOTION

Helpless ResignedDe-skilled EnragedAngry FrustratedPunitiveManipulatedTrickedHopeless

Vicarious Traumatization and Countertransference

Counter transference: Reactions you have to a particular

individual based on who you are and who the individual is.

Vicarious Traumatization The effect on you—over time and across

clients—of clinical work with traumatized individuals

Burnout and Secondary Traumatic Stress—College Buddies

I am unhappy I feel disconnected from others I feel trapped by my job My beliefs don’t sustain me I am not the person I always

wanted to be I feel worn out because of my

work as a helper I feel overwhelmed because my

case load seems endless I feel ‘bogged down’ by the

system I am less caring than I used to be

I am preoccupied with more than one person I help I jump or am startled by unexpected sounds I find it difficult to separate my personal life from

my life as a helper I am not as productive at work because I am losing

sleep over traumatic experiences of a person I help I think that I might have been affected by the

traumatic stress of those I help I feel depressed because of the traumatic

experiences of the people I help Because of my helping, I have felt ‘on edge’ about

various things I feel as though I am experiencing the trauma of

someone I have helped. I avoid certain activities or situations because they remind me of frightening experiences of the people I help

As a result of my helping, I have intrusive, frightening thoughts.’

I can’t recall important parts of my work within patients.

BurnoutSecondary Traumatic Stress

Sources of stress

Hurried providers Misunderstandings about the work Upset

clients/families/colleagues/community partners

Exhausting schedules Heartbreaking stories

Impact of Stress

Poor concentrationMemory ProblemsIrritabilitySleeplessnessHeadachesIncreased blood pressureDecreases immunityHeart disease

Resiliency Planning

Individual, personally Assessing compassion fatigue and compassion

satisfaction can help you plan where to put your energy to increase your resilience

Organizational planning Can help organizations find ways to maximize the

positive aspects and reduce the negative aspects of helping

Supportive supervision Self assessment can be used as information for

discussions. Peer groups can be insightful

Managing Stress

Self care The basics

Food, rest, relaxation, beauty, connection, laughter Self Nurture

Being good to yourself Massage, enjoyment, leisure, good smells, good food, good

texture, relaxing yourself through your senses, having fun. Escape

Building time for yourself Time enough to eat (lunch!), take restroom breaks, to be

alone, to be in a soothing location, to take vacations(not to be confused with family visits!)

traumaticstressconsulting.comTrauma & Recovery by Judy HermanBruce Perry, childtrauma.orgACES onlineGoogle scholar

Resources