A Trauma-Informed Understanding of Suicidality Elizabeth Hudson, LCSW Consultant to WI Dept. of Health Services Employed by University of Wisconsin - Madison.

A Trauma-Informed Understanding of Suicidality

Elizabeth Hudson, LCSWConsultant to WI Dept. of Health Services

Employed by University of Wisconsin - Madison

Psychological Trauma - What is it?Extreme stress (e.g., threat to life, bodily integrity or sanity) that overwhelms a person’s ability to cope.

The individual’s subjective experience determines whether or not an event is traumatic.

Traumatic events result in a feelings of vulnerability, helplessness and fear.

Traumatic events often interfere with relationships and fundamental beliefs about oneself, others and one’s place in the world.

Posttraumatic Stress Disorder = re-experiencing, avoidance/numbing & hyperarousal

)

Psychological Trauma - Examples• Violence in the home, personal relationships,

workplace, school, systems/institutions, or community

• Maltreatment or abuse: emotional, verbal, physical, sexual, or spiritual

• Exploitation: sexual, financial or psychological

• Abrupt change in health, employment, living situation over which people have no control

• Neglect and deprivation

• War or armed conflict

• Natural or human-caused disaster

Trauma-related Statistics

56% of the general population reported at least one traumatic event (Kessler,1995)

90% of mental health clients have been exposed to a traumatic event and most have multiple exposures

(Muesar, 1998)

83% of females and 32% of males with developmental disabilities have experienced sexual assault. (Hard, 1986) Of those who were assaulted, 50%

had been assaulted 10 or more times (Sobsey and Doe, 1991)

97% of homeless women with mental illness experienced severe physical and/or sexual abuse (Goodman, Dutton et al., 1997)

Trauma has been associated with suicide-related thoughts or behaviors in populations such as:

– Vietnam veterans (Fontana and Rosenheck, 1995), – American Indians (Robin et al., 1997), – psychiatric inpatients (Sfoggia et al., 2008), – people with substance disorders (Roy et al., 2007), – medical students (Jeon et al., 2009), – college students (Bryant and Range, 1997), – adolescents (Lipschitz et al., 1999), – military men and women (Hoge et al., 2004).

Adverse Childhood Experience (ACE) Study

http://www.acestudy.org/

http://www.cdc.gov/nccdphp/ACE/

‘ACE’

Abuse

• Psychological (by parents)

• Physical (by parents)

• Sexual (anyone)

• Physical neglect

• Emotional neglect

Household with:

• Substance abuse

• Mental illness

• Separation/divorce

• Domestic violence

• Imprisoned household member

Childhood Experiences Underlie Suicide

0

5

10

15

20

25

% A

ttem

ptin

g S

uici

de

ACE Score

11

22

00

33

4+4+

Complex Trauma / Complex PTSD / Developmental Trauma Disorder

Result of traumatic experiences that are interpersonal, intentional, prolonged and repeated

Symptoms of Complex TraumaRe-experiencing Avoidance/ Numbing Arousal

PLUS• Emotional difficulties: managing feelings; chronic anxiety;

empathizing; low frustration tolerance; expressing needs, thoughts, concerns using words

• Cognitive difficulties: cognitive biases; understanding what is being said; doing things in logical sequence; seeing ‘gray’; working with time; multiple ideas simultaneously; maintaining focus

• Social difficulties: attending to or accurately assessing social cues; connecting with others; seeking attention in appropriate ways; appreciating how behavior impacts others

• Handling transition and change: impulsive; adapting to change; handling unpredictability, ambiguity, uncertainty & novelty

• Interference with developmental momentum: social withdrawal; decreased range of affect; regression in development; decrease in play

Impact on WorldviewImpact on WorldviewTypical Development vs. Developmental TraumaTypical Development vs. Developmental Trauma

• Nurturing & stable attachments with adults

• Belief in a predictable & benevolent world/ generally good things will happen to me

• Feeling of positive self-worth /others will see my strengths

• Optimism about the future• Feeling that I can have a

positive impact on the world

• Basic mistrust of adults/inability to depend on others

• Belief that the world is an unsafe place/bad things will happen & they are usually my fault

• Assumption that others will not like me

• Fear & pessimism about future

• Feelings of hopelessness & lack of control

Mediating or Exacerbating FactorsPerson• Age / developmental stage• Past experiences and coping skills

Environment• Presence of sensitive & supportive ‘other’• Safe community• Access to supportive resources• Culture and cultural beliefs

Event• Severity & chronicity• Interpersonal vs. act of nature• Intentional vs. accidental

Suicidality and Surviving Trauma: Shared Elements

People often…

– aren’t asked– don’t tell– feel they have secret and experience shame– experience failure and sense of unworthiness– feel isolated and alone– feel helpless and hopeless– feel detached– have impaired judgment and self-regulation

(Hodas, 2008)

Providers Respond …

• Hospitalization

• Psychotropic medication

• Outpatient treatment

Trauma-Informed Care

What it is:

a philosophical shift

What it is not:

an intervention to address PTSD

-----------------------Moving from, ‘What’s wrong with you’

to

‘What’s happened to you?’

Shneidman’s Two Questions

Where do you hurt?

How can I help?

(McCord, Marian University, September, 2011)

Trauma-Informed Care – What is it?

Incorporate knowledge about trauma – prevalence, impact, and recovery – in all aspects of service delivery

Place priority on:1. meaningful consumer engagement 2. physical and emotional safety 3. choice4. collaboration / sharing power5. empowerment and skill building (1-5, Fallot & Harris)

6. healing relationships

Increase caregiver capacity

Guiding Values of Trauma-Informed Care

Healing Happens in Relationship

TIC within Suicide Prevention: Beliefs

• People often feel out of control, but don’t talk about it

• Core considerations: avoid power struggles and the use of shame & humiliation

• People need…– trusting relationships– information for self-awareness and goals– to develop more effective coping skills– support in regaining hope

(Hodas, 2008)

TIC within Suicide Prevention: Practices

• Address any continuing trauma or danger

• Actively engage and build relationship

• Be welcoming and non-judgmental

• Build on strengths

• Gather trauma and treatment history

• Anticipate needs and intervene early

• Ensure that treatment is available and appropriate

(Hodas, 2008)

TIC within Suicide Prevention: Practices

• Help people…– understand trauma history, symptoms &

behaviors, impact on life and how to change

– learn to recognize & control triggers

– Approach ‘failures’ as opportunities to learn

• Promote…– self-expression

– acquisition of social skills

– coping & wellness(Hodas, 2008)

Tool: WRAP Plan

WRAP Plan should address:

– Preferred ways of calming

– Triggers

– Signs and symptoms of triggers

– What people want helpers to do and not to do

– What people want to be encouraged to do

– Identification of others who can provide support

http://www.indianamentalhealthneeds.org/files/Advocate_WRAPIntro.pdf(Hodas, 2008)

Trauma Resources

• National Center for Trauma-Informed Care http://mentalhealth.samhsa.gov/nctic/

• National Center for Posttraumatic Stress Disorder http://www.ncptsd.org

• National Child Traumatic Stress Networkhttp://www.nctsn.org

• International Society for Traumatic Stress Studies http://www.istss.orgI

• International Society for the Study of Trauma and Dissociation http://www.isstd.org

• The Anna Institute. http://www.annafoundation.org/

Sample of Models, Guides and Resources

The Anna Institute. http://www.annafoundation.org/

Developing Trauma-Informed Organizations, Inst. for

Health and Recovery. http://www.healthrecovery.org/

Risking Connection, Sidran Institute.http://www.riskingconnection.com/

The Sanctuary Model, CommunityWorks. http://www.sanctuaryweb.com/

Using Trauma Theory to Design Service Systems,

Fallot & Harris, Community Connections.

School and Teaching ResourcesHelping Traumatized Children Learn

Massachusetts Advocates for Children 2005 http://www.massadvocates.org/helping_traumatized_children_learn

The Heart of Learning & Teaching Compassion, Resiliency & Academic Success

Wolpow, Ray; Johnson, Mona M.; Hertel, Ron; Kincaid, Susan O. 2009 http://k12.wa.us/CompassionateSchools/HeartofLearning.aspx

Creating Sanctuary in Schools 1995

Bloom, Sandra http://www.sanctuaryweb.com/Documents/Sanctuary%20in%20the%20School.pdf

Child Trauma Toolkit for Educators

National Child Traumatic Stress Network http://www.nctsnet.org/nctsn_assets/pdfs/Child_Trauma_Toolkit_Final.pdf

Credits

Multiple slides were taken from the work of…

• Gordan Hodas, Pennsylvania 2nd Annual Suicide Prevention Conference, Trauma-Informed Care & Youth Suicide Prevention (2008)

• Janet McCord, Marian University of Fond du Lac, Shneidman in a Nutshell: Psychache and Suicide (2011)

Contact Information

Elizabeth Hudson, LCSWTrauma-Informed Care Consultant

WI Dept. of Human Services

Division of Mental Health and Substance Abuse Services

608-266-2771

[email protected] by University of Wisconsin -

School of Medicine and Public Health