Trauma Informed and Trauma Specific Practices

1. Trauma Informed and Trauma Specific Practices Adult Criminal Justice Treatment and Offender Reentry Program Grantee Meeting Santa Ana Pueblo NM September 30, 2010 Kath Schilling, M.Ed., CAS, LADC I Institute for Health and Recovery www.healthrecovery.org Note: This presentation assumes an organization is already taking into account issues of culture, ethnicity, race, religion, gender, ability, sexual orientation, literacy, language ,and economic disadvantage in service design and delivery. Institute for Health and Recovery 1

2. Trauma Definition Extreme stress that overwhelms a person’s ability to cope A normal response to an abnormal event An experience of a threat to life, bodily harm or sanity Only the individual can decide whether an event or experience is traumatic Institute for Health and Recovery 2

3. Physical Assault Sexual Abuse including sex work Emotional/ Psychological Abuse Domestic Violence War/Genocide Accidents Natural or Man-Made Disaster Historical Trauma Witnessing abuse/violence Living in dangerous environment Experienced as an adult or child Occurred over time or one incident or time limited Traumatic Events Institute for Health and Recovery

4. TRAUMATIC EVENTS ARE EXTRAORDINARY not because they occur rarely, but rather because they overwhelm the ordinary human adaptations to life. Unlike commonplace misfortunes, traumatic events generally involve threats to life or bodily integrity, or a close personal encounter with violence or death. They confront human beings with the extremities of helplessness and terror and evoke the responses of catastrophe. The common denominator of trauma is a feeling of intense fear, helplessness, loss of control and threat of annihilation. Judith Herman, 1992 Institute for Health and Recovery

5. Adverse Childhood Experiences(ACE) Study • Sample of 17,000 Kaiser Permanente middle class American adults of diverse ethnicity • Large-scale epidemiological study of influence of stressful/traumatic childhood experiences • Investigating adverse childhood experiences against adult health status • Found compulsive use of nicotine, alcohol, and injected street drugs increases proportionally in a strong, graded, dose-response manner that closely parallels the intensity of adverse experiences in childhood. Fellitti & Anda, 1998 Institute for Health and Recovery

6. ACE Study (Felitti, 2003) Institute for Health and Recovery

7. ACE Study • Scoring system used—one point for each category of Adverse Childhood Experiences (ACE) before 18 • ACE’s not only common, but effects were cumulative • Compared to persons with ACE score of 0, those with ACE score of 4 or more were 2x more likely to be smokers, 12x more likely to have attempted suicide, 2x more likely to be alcoholic and 10x more likely to have injected street drugs Institute for Health and Recovery

8. ACE Study Controlling for other adverse childhood events • Women with a history of childhood sexual abuse were 60% more likely to have alcohol problems and 70% more likely to have used illegal drugs. • Men with a history of childhood sexual abuse were 30% more likely to have alcohol problems and 60% more likely to have used illegal drugs. • (Dube et al., 2005) Institute for Health and Recovery

9. History of Childhood Abuse Among Offenders with Substance Use Problems Messina et al. (2007) Institute for Health and Recovery

10. Household Dysfunction among Offenders with Substance Use Problems Messina et al. (2007)

11. Impact of Substance Use on Offenders • Women report more abuse, men report more dysfunction • For both men and women, more childhood adverse events associated with • mental health or drug treatment prior to prison • use of psychotropic medication • earlier regular drug use • earlier first arrest Messina et al. (2007) Institute for Health and Recovery

12. Traumatic Distress • For both men and women, increased traumatic distress is associated with increased childhood adverse event • However, women have higher levels of traumatic distress overall Messina et al. (2007) Institute for Health and Recovery

13. The Impact of Trauma

14. “…Once I became trauma informed, I remember realizing one day what perfect sense this all makes. I was able to finally fit the pieces of the puzzle together. Being a survivor was the reason I drank & used drugs. Post Traumatic Stress Disorder had set in, & the drinking and using suppressed my true feelings. I am among one of the lucky few. So many of us have not solved the puzzle—survivors, & providers.” Why Trauma Matters Institute for Health and Recovery

15. Impact of Trauma: Beliefs About self About other people About the world Institute for Health and Recovery 15

16. Impact of Trauma: Physiological Changes in brain chemistry and physical health that can change emotional control and distort thinking, perceptions and behavior Institute for Health and Recovery 16

17. Impact of Trauma: Cognitive Blocking Flashbacks Dissociation Confusion Difficulty concentrating Institute for Health and Recovery 17

18. Impact of Trauma: Emotional Fear, terror Anger, revenge, hate Frustration Guilt or self-blame (legitimate, illegitimate) Shame, humiliation Grief or sorrow Feelings become either numbed or overwhelming Institute for Health and Recovery 18

19. Impact of Trauma: Skill Deficits May distort what they hear and see Hear only a few words spoken to them Not be able to think things through Behave impulsively Resort to old behaviors and coping skills Institute for Health and Recovery 19

20. Impact of Trauma: Relational Self-awareness Self-protection Self-soothing/emotional modulation Relational mutuality / Empathy / Authenticity Accurate labeling of self and others A sense of purpose and meaning to life Institute for Health and Recovery 20

21. Trauma-Informed Services Institute for Health and Recovery

22. Trauma-Informed Services • Trauma-informed services are based on an understanding of the impact of violence and victimization. • All services for individuals in the criminal justice system with substance use/ co-occurring disorders should be trauma-informed. Institute for Health and Recovery

23. Failure to Understand and Address Trauma Can Lead to: • Failure to engage in treatment services (Farley, 2004) • Increase in symptoms (eating disorders, self-harm) • Increase in management problems • Retraumatization (Harris and Fallot, 2001) • Increase in relapse • Withdrawal from service relationship • Poor treatment outcomes (Easton et al 2000; Ouimette et al 1999) Institute for Health and Recovery

24. Principle 1:Trauma is Central and Pervasive • Central to the development of mental health and addiction problems • Impacts MANY aspects of a person’s life Institute for Health and Recovery

25. Principle 2:Universal Precautions • Treat everyone as if they may have experienced trauma. • An individual should not have to disclose trauma to receive trauma-informed services Institute for Health and Recovery

26. Principle 3:Symptoms and Behaviors Are often attempts to cope with the trauma Institute for Health and Recovery

27. Common Coping Behaviors substance use unsafe sexual practices reconnecting with abusive family reconnecting with batterers shoplifting smoking promiscuity cutting eating disorders scratch tickets gambling Institute for Health and Recovery

28. Principle 4:Goal of Services Is to return a sense of autonomy and control to the person being served Institute for Health and Recovery

29. Guidelines for Trauma-Informed Services Establish a safe environment Use an empowerment model Support the development of healthy relationships Build healthy coping skills Provide access to trauma-specific services Are holistic Institute for Health and Recovery Institute for Health and Recovery

30. Establishing a Safe Environment Physical safety—from abuse/stalking by partners, family, other consumers, visitors, staff Emotional safety—in which anindividual’s experience is validated and his or her needs are addressed Minimize revictimization by reducing potential triggers Institute for Health and Recovery Institute for Health and Recovery

31. Empowerment Model • Establish a collaborative relationship • Involve individual in design, delivery and evaluation of services • Respect individual’s need for choice and control • Focus on strengths • Build skills • Acknowledge current socio-political and cultural context Institute for Health and Recovery

32. Focus on the development of trustworthy, empathic, mutual, authentic relationships • Between service staff and clients • Among clients in service setting • In developinga support system outside of service setting Staff should MODEL healthy relationships Institute for Health and Recovery

33. Building Healthy Coping Skills Emotional self-awareness Grounding Self-soothing Making safer choices Institute for Health and Recovery Institute for Health and Recovery 33

34. Trauma Informed Substance Abuse Treatment Institute for Health and Recovery

35. Substance abuse increases the risk that men will batter their partners, although substance abuse does not CAUSE domestic violence. The impact of violence on both men and women is inadequately understood and addressed by service providers Less than half of the women with interpersonal trauma and co-morbidity will receive treatment that addresses their trauma history and co-occurring conditions. (Timko & Moos, 2002) The Reality Is… Institute for Health and Recovery

36. Treatment Programs Often Fail to Adequately Deal with Trauma. Why? • Lack of research/knowledge dissemination; training • Trauma not seen as central/critical to recovery • Fear that “uncovering” trauma would “destabilize” symptoms—need to stabilize mental health/ substance abuse—Opening a “Pandora’s Box” • A belief that trauma work requires more sophisticated clinical skills Institute for Health and Recovery

37. Similarities Between Criminal Justice Involvement, Violence and Addiction • Involve power and control dynamics • Impact entire families through generations • Thrive in silence and isolation • Carry great societal stigma and shame • Involve denial systems including: • Minimizing • Rationalizing • Justifying Institute for Health and Recovery

38. Special Issues of Victims of Violence Who Are Substance Abusers The presence of both substance abuse & domestic violence increases the severity of injuries & lethality rates(Mackey, 1992) Perpetrators may pose risk to partners by: • Introducing partner to drugs • Forcing or coercing partner use • Isolating partner from help • Coercing partner to engage in illegal acts • Using withholding drugs as a threat • Using legal history as a threat • Blaming abuse on partner use Institute for Health and Recovery

39. Service Elements of Trauma-Informed Treatment • Universal screening for • Current safety • History of trauma • Trauma symptoms • Substance use and abuse • Mental health problems Institute for Health and Recovery

40. Service Elements of Trauma-Informed Treatment • Psycho-education for participants regarding • Trauma (including domestic violence) • Impact of trauma • Relationship of trauma to substance use, mental health and criminalality • Access to safety planning • Emphasis on building safe coping skills • Access to trauma-specific groups Institute for Health and Recovery

41. Service Elements of Trauma-Informed Treatment • Crisis Prevention Plans that include • Triggers—actions or events that cause distress for each participant • Early warning signs that indicate distress • Participant’s understanding of what helps them calm down • Agreements about what staff will offer in a difficult situation Institute for Health and Recovery

42. What Helps When Individuals Become Upset? Remain calm; model self-control If you must intervene in a flashback, help focus attention on here and now Restore control by offering choices rather than giving ultimatums Look at pros and cons of different choices Institute for Health and Recovery 42

43. Lack of control-powerlessness Threat or use of physical force Observing threats, assaults, others engaged in self-harm Isolation Being in a locked room or space Physical restraints—handcuffs, shackles Interacting with authority figures Incarceration Interacting with men, in general Lack of privacy Removal of clothing—strip searches, medical exams Being touched—pat downs Being watched—suicide watch Loud noises Fear based on lack of information Darkness Intrusive or personal questions Triggering Situations for Survivors of Trauma/ Violence Institute for Health and Recovery

44. Trauma-Informed vs. Trauma-Specific Treatment • Trauma-informed; basic training/education to all staff—from secretaries to high level administrators—understanding of trauma permeates every aspect of treatment milieu and interventions. • Trauma-specific treatment; educating fewer, carefully selected staff/clinicians to conduct actual trauma treatment Fallot & Harris, 2001; Najavits, 2006 Institute for Health and Recovery

45. Helpful Integrated Concepts • Understand the relationship of criminal justice involvement, substance use, mental illness and violence for this client • Symptoms and behaviors (including substance use) as attempts to cope • Making safe choices • Trauma recovery skills Institute for Health and Recovery

46. Trauma-SpecificServices for Adults Lisa Najavits Seeking Safety Stephanie Covington Beyond Trauma Maxine Harris Trauma Recovery and Empowerment (TREM) Dusty Miller Addiction and Trauma Recovery Integration Model (ATRIUM) Institute for Health and Recovery 46

47. Trauma-SpecificServices for Adults (cont.) Julian Ford Trauma Adaptive Recovery Group Education and Therapy for Persons in Recovery from Addiction (TARGET–AR) Eye Movement Desensitization and Reprocessing (EMDR) Dialectical Behavior Therapy (DBT) Institute for Health and Recovery 47

48. References Elliott, D.E., Bjelajac, P., Fallot, R.D., Markoff, L.S., & Glover Reed, B. (2005). Trauma-informed or trauma-denied: Principles and implementation of trauma-informed services for women. Journal of Community Psychology, 33(4),461–475. Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, Marks JS. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The adverse childhood experiences (ACE) study. American Journal of Preventive Medicine. 1998;14:245-258 Finkelstein, N., VandeMark, N., Fallot, R., Brown, V., Cadiz, S., & Heckman, J. (2004). Enhancing substance abuse recovery through integrated trauma treatment. Sarasota, FL: National Trauma Consortium, Center for Substance Abuse Treatment. Harris, M., & Fallot, R.D. (Eds.). (2001). Using trauma theory to design service systems. New Directions for Mental Health Services. San Francisco, CA: Jossey-Bass/Pfeiffer. Herman, J. (1992). Trauma and Recovery. New York: Basic Books, Harper Collins Publishers. Messina, N. , Grella, C. , Burdon, W. and Prendergast, M. , 2007-11-14 "Childhood Adverse Events and Adult Mental Health Among Men and Women Prisoners" Paper presented at the annual meeting of the AMERICAN SOCIETY OF CRIMINOLOGY, Atlanta Marriott Marquis, Atlanta, GeorgiaOnline <PDF>. 2010-06-07 from http://www.allacademic.com/meta/p199647_index.html Institute for Health and Recovery