John R. Kasich, Governor Tracy J. Plouck, Director John L. Martin, Director 1 Developmental Disabilities Mental Health and Addiction Services.

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Trauma-Informed Care Initiative

Addiction Studies Institute August 7, 2014

John R. Kasich, GovernorTracy J. Plouck, DirectorJohn L. Martin, Director

Developmental Disabilities Mental Health and Addiction Services

What is trauma?

Individual trauma results from an event, series of events, or a set of circumstances

that is experienced by an individual as physically or emotionally harmful or

threatening and that has lasting adverse effects on the individual’s functioning and

physical, social, emotional, or spiritual well-being

(SAMHSA)2

What is trauma?

The individual’s experience of these events or circumstances helps to determine whether it is a traumatic event. The long-lasting adverse effects on an individual are the result of the individual’s experience of the event or circumstance.

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Prevalence of trauma

Exposure to trauma is widespread• Trauma can occur at any age• Trauma can affect individuals from all

walks of life

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Prevalence of trauma

Exposure to trauma is especially common among individuals with mental illness, substance use disorders and developmental disabilities

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Trauma Affects…

Over one out of three females with mental health disorder; and

About one out of five males with mental health disorder in Ohio

Source: Client Self-Reported Experiences of Trauma, SFY13, Ohio Behavioral Health Module

Trauma Affects…

Over one out of four females with a substance use disorder; and

About one out of ten males with a substance use disorder in Ohio

Source: Client Self-Reported Experiences of Trauma, SFY13, Ohio Behavioral Health Module

Prevalence of trauma

• NIDA suggests that up to two thirds of individuals with substance use disorders have experienced trauma

• Rape victims are three times as likely to use marijuana, six time mores likely to have used cocaine and ten times as likely to have used other drugs, including heroin and amphetamines

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Trauma affects…

Over one out of three females with co-occurring mental health and substance use disorders; and

Over one out of ten males with co-occurring mental health and substance use disorders in Ohio

Source: Client Self-Reported Experiences of Trauma, SFY13, Ohio Behavioral Health Module

Trauma affects Ohioans with Developmental Disabilities…

Neglect

1116366

Physical Abuse

310

Verbal Abuse

83

Sexual Abuse

CRN Validation Cube. Ohio Department of Developmental Disabilities 2013.

Ohioans with Developmental Disabilities…

Increased risk for abuse as compared to the general population (Gil, 1970; Mahoney & Camilo, 1998; Ryan, 1994)

Over four times as likely to be victims of crime (Sobsey, 1996)

Two – ten times more likely to be sexually abused than those without disabilities (Westat Ind., 1993)

Often experience rejection and loneliness (Pitonyak)

Trauma affects Ohio’s children…

29600

Neglect

Physical Abuse

2750012600

Foster care

12100

Multiple Allegations

10600

Sexual Abuse

1800

Emotional Abuse

PCSAO Fact Book: 11th Edition, 2013-2014, Public Children Services Association of Ohio

• In 2013, 15,000 Ohio children of a substance-abusing guardian entered the county child-welfare system

• At least half of these children remained in the county’s custody for more than 300 days compared with the average 70-day stay

• Child abuse and neglect reports in which heroin was listed as a factor increased from 4.9% of total reports in 2010 to 8.9% 2013

Substance use and impact on child welfare

Ohio Department of Job and Family Services, Office of Families and Children

Trauma affects Ohioans with domestic violence…

Statistic correlation with substance use with victims.

Domestic Violence Calls

(68,000)

Victims (56,000)

Arrests (41,000)

Barbara Warner Committee on Workplace Domestic Violence -2013 Report, Ohio Department of Health Ohio Domestic Violence Statistics, 2012,

Ohio Domestic Violence Network HealthDay, Copyright © 2013

Trauma Affects Ohioans with Domestic Violence…

Of families who experience intimate partner violence:

• Four out of five adult children commit violence against partners

• Three out of four adult children become victims of domestic violence

Barbara Warner Committee on Workplace Domestic Violence -2013 Report, Ohio Department of Health Ohio Domestic Violence Statistics, 2012,

Ohio Domestic Violence Network HealthDay, Copyright © 2013

Trauma Affects Ohioans Who Are Victims of Human Trafficking…

Ohio ranks fifth among all US states in human trafficking

1000 Ohio children are estimated to become victims of human trafficking each year

Substances can be used to coerce potential victims

Substances may be used by victims to cope with desperate situations

NOT FOR SALE

http://humantrafficking.ohio.gov

Cost of trauma

• Trauma is a major driver of medical illness, including cardiac disease and cancer

• Trauma is a major factor contributing to substance usage resulting in physical/psychological problems exacerbated by chemicals.

• Addressing trauma can positively impact the physical, behavioral, social and economic health of Ohio and Ohioans

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Adverse Childhood Experiences Study

• Collaboration between Kaiser Permanente and CDC

• 17,000 patients undergoing physical exam provided detailed information about childhood experiences of abuse, neglect and family dysfunction (1995-1997)

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ACE Categories

Abuse• Emotional• Physical• Sexual

Neglect• Emotional• Physical

Household Dysfunction• Mother Treated Violently• Household Substance Abuse• Household Mental Illness• Parental Separation or Divorce• Incarcerated Household Member

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ACE Categories

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ACE Score and Health Risk

As the ACE score increases, risk for these health problems increases in a strong and graded fashion:

• Alcoholism and alcohol abuse

• Chronic obstructive pulmonary disease (COPD)

• Depression• Hallucinations• Fetal death• Decline in Health-related quality of life

• Illicit drug use• Ischemic heart disease (IHD)• Liver disease

• Risk for intimate partner violence• Multiple sexual partners• Sexually transmitted diseases (STDs)

• Smoking• Suicide attempts• Unintended pregnancies

• Early initiation of smoking• Early initiation of sexual activity• Adolescent pregnancy• HIV

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ACE Score and Health Risk

As the ACE score increases, risk for these health problems increases in a strong and graded fashion:

• Alcoholism and alcohol abuse• Chronic obstructive pulmonary

disease (COPD)• Depression• Hallucinations• Fetal death• Decline in Health-related quality

of life• Illicit drug use• Ischemic heart disease (IHD)• Liver disease

• Risk for intimate partner violence

• Multiple sexual partners• Sexually transmitted diseases

(STDs)• Smoking• Suicide attempts• Unintended pregnancies• Early initiation of smoking• Early initiation of sexual activity• Adolescent pregnancy• HIV 22

ACE Pyramid

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What is Trauma Informed?

A program, organization or system that is trauma-informed:• Realizes the widespread prevalence and impact of trauma • Understands potential paths for healing• Recognizes the signs and symptoms of trauma which includes the

usage of substances and how trauma affects all people in the organization, including:• Patients• Staff• Others involved with the system

• Responds by fully integrating knowledge about trauma into practices, policies, procedures, and environment.

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Key Principles of Trauma-Informed Care

• Safety• Trustworthiness and transparency• Collaboration and mutuality• Empowerment• Voice and choice• Peer support and mutual self-help• Resilience and strength-based• Inclusiveness and shared purpose• Cultural, historical and gender issues• Change process• Proper referrals for Mental Health and Substance treatment as

deemed necessary

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Outcomes with TIC

• Improved quality of care and impact of care• Improved safety for patients and staff• Decreased utilization of seclusion and restraint• Fewer no-shows• Improved patient engagement• Improved patient satisfaction• Improved staff satisfaction• Decreased “burnout” and staff turnover

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Ohio’s Trauma Informed-Care (TIC) Initiative

• Many mental health and addiction treatment agencies, inpatient facilities, child-serving agencies and other community partners, have already provided training and consultation in trauma informed practice

• Many clinicians are trained in Trauma-Focused Cognitive Behavioral Therapy (TF-CBT), Eye Movement Desensitization training (EMDR); Dialectical Behavioral Therapy (DBT) and other treatment modalities

• Trauma Informed Care is not the same as PTSD treatment

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Ohio’s Trauma-Informed Care (TIC) Initiative

• There continues to be a need for training for staff/facilities and community system partners

• The ability of all communities and providers to organize trauma

trainings internally is often beyond their finances, time and capabilities, yet the need of persons served has not changed

• The initiative will seek to provide additional resources for agencies and programs in Ohio who may need this support

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Ohio’s Trauma-Informed Care (TIC) Initiative

• Since Summer of 2013, an interagency workgroup comprised of leaders from Ohio MHAS and Ohio Department of Developmental Disabilities (DODD) has been meeting to formulate plans to expand TIC across the state

• A portion of the “Strong Families, Safe Communities” funds from the Governor’s Office have been earmarked for this purpose

• The National Center for Trauma-Informed Care (NCTIC)/SAMHSA and Ohio Center for Innovative Practices (CIP) have also consulted formally

• Additional conversations and advice from Ohio Hospital Association, OACBHA, Ohio Council, PCSAO, and many others (thanks!)

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Ohio’s Trauma-Informed Care (TIC) Initiative

Vision:To advance Trauma-Informed Care in Ohio Mission:To expand opportunities for Ohioans to receive trauma-informed interventions by enhancing efforts for practitioners, facilities, and agencies to become competent in trauma- informed practices

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Ohio’s TIC InitiativeTrauma-Informed Care • The TIC model assesses a service delivery system and makes

modifications based on the basic understanding of how trauma affects the life of an individual seeking services

• TIC means that every part of an organization or program understands the impact of trauma on the individuals they serve and promotes cultural and organization change in responding to the consumers/clients served

• This is not a service; rather it is an approach to interpersonal interactions that takes into account the potential scars of a person’s past experience

• The TIC Initiative is not about endorsing particular trauma-informed practices, treatment models, screening or assessment instruments or processes and takes an across-the lifespan approach

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Trauma-Informed Care (TIC) Promotes Cultural Change

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“What’s wrong with you?”

“What has happened to you?”

Interdepartmental Leadership Team

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• Dr. Mark Hurst, OhioMHAS, Co-Chair

• Kathy Coate-Ortiz, OhioMHAS

• Jody Lynch, OhioMHAS• Angie Bergefurd,

OhioMHAS• Trudy Sharp, OhioMHAS• Dr. Lisa Gordish, Twin

Valley RPH• Dr. Kraig Knudsen,

OhioMHAS• Latonya White, OhioMHAS

• Pam Berry, DODD, Co-Chair• Sarah Lawson, DODD• Angela Sausser-Short, Ohio

MHAS• Patrick Kanary, CIP, Case

Western Reserve University• Joyce Starr, OhioMHAS• Dr. Tammy Collins, OhioMHAS• Jackie Doodley, OhioMHAS• Dr. Afet Kilinc, OhioMHAS• Rob Robbins, DODD• Kim Kehl, OhioMHAS

Framework for Ohio’s TIC Initiative

Progress: Statewide

• TIC Project Coordinator • Statewide Advisory Committee• Meets monthly• Endorsed “Fundamentals of TIC” approach• Serve as “ambassadors” of TIC

• Partnership with National Center for Trauma-Informed Care NCTIC • Train-the-trainers model• System infrastructure and infiltration

• Updated TIC Website (in progress):• http://mha.ohio.gov/Default.aspx?tabid=104

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TIC Advisory Committee:

• Survivors of Trauma• DODD• Ohio Hospital Association• Medicaid• PCSAO• OACBHA• Ohio Council• OACCA• ODH• Hamilton County Board of DD• ODE

• Wright State University: MI/DD CCOE

• Depart of Aging• Human Trafficking Commission• CIP• ODJFS• ODYS• Ohio Women’s Network• Board of Regents• Center for the Treatment and

Study of Traumatic Stress• Ohio Provider Resources

Association (DD)

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Framework for Ohio’s TIC Initiative

TIC Summit - June 26, 2014Creating Environments of Resiliency and Hope• Thematic fundamental training for clinical and

administrative leaders• AM session: Didactic by leaders from NCTIC• PM session: Regional breakouts to advance TIC locally• Identify strengths, weaknesses, needs, champions• Identify initial plan to proceed, with support from

departments for communication, facilitation, etc.• Sustainability

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Framework for Ohio’s TIC Initiative

Regional Collaboratives• Progressively transmit TIC and increase expertise within

regions• Facilitate cultural change within organizations,

addressing gaps and barriers and taking effective steps based on the science of implementation

• Topical workgroups (prevention, DD, child, older adult, etc.)

• Department(s) continue to support, facilitate, communicate

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Framework for Ohio’s TIC Initiative

Sustainability:

• Based on the passion of those involved in the initiative• This can be launched and maintained with fairly little

infusion of resources• Encourage use and repurposing of existing resources• Technical support: NCTIC and deliverables of CCOEs• Encourage regions and states to develop internal expertise

and learning communities to transmit, maintain and advance our ability to respond to those with trauma needs

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TIC: Why is this important?

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TIC: Why is this important?

“What Happened to You?”

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Resources

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• Ohio Department of Developmental Disabilities• National Center for Trauma-Informed Care• OhioMHAS Office of Research• Public Children’s Services Association of Ohio• Ohio Human Trafficking Commission• Ohio Department of Health• Ohio Domestic Violence Network• SAMHSA• Ohio MHAS Trauma Website: http://

mha.ohio.gov/Default.aspx?tabid=104