Day 2 | CME- Trauma Symposium | Beh health issues to self inflicted injuries
Trauma Informed Care Module 2
1. Trauma Informed Care: A
New Perspective of
Quality Care
MODULE II TRAUMA AWARENESS
TIPPI WATSON, MPH, BCHS
2014
2. Objectives
By the end of this class students will be able
to :
Recognize the types of trauma
Articulate the differences in the types of traumas
Recognize the objective characteristics of trauma
Recognize the subjective characteristics of trauma
Identify the factors that influence how people deal with trauma
3. Refresher
Trauma
“trauma results from an event, series of events, or set of circumstances that
is experienced by an individual as physically or emotionally harmful or
threatening and that has lasting adverse effects in the persons functioning
and physical , social, emotional or spiritual well being.” (SAMHSA, 2014, p.2)
Trauma informed care
“a strengths based service delivery approach that is grounded in an
understanding of and responsiveness to the impact of trauma, that
emphasizes physical, psychological, and emotional safety for both providers
and survivors to rebuild a sense of control and empowerment.” (SAMHSA, 2014, p.xix)
Resiliency
The ability to thrive despite negative life experiences and heal from
traumatic events. It is directly related to the internal strengths and
environmental supports of an individual. (SAMHSA, 2014)
4. SAMHSA endorses adherence to 6
key principles in a trauma
informed approach
Safety
Trustworthiness and Transparency
Peer support
Collaboration and mutuality
Empowerment, voice and choice
Cultural, Historical, and Gender Issues
6. Types of Trauma
Natural trauma
Acts of God/Nature
Unavoidable events
Human caused traumas
Caused by human failure
Caused by human design
7. Natural events and their trauma
Our response is dependent on several
factors:
Degree of devastation
The extent of individual and community loss
The amount of time it takes to re-establish
daily routines, activities and services
8. The response to natural events can
also impact the trauma survivors.
Relief services
Presences of community members and
outsiders in the affected area
Consequences of the event and the
response of the community
9. Human Caused traumas
The two kinds of human caused traumas are fundamentally different
from natural disasters;
Intentional
robbery
acts of terrorism
school shootings
Unintentional
Bridge collapse
Car accident
Ferry sinking
11. Subgroups of Trauma
Individual trauma
Interpersonal trauma
Developmental
Group trauma
Political, war, refugee
Community or cultural
Historical
Mass trauma
System trauma
Institutional
Governmental
12. Individual Trauma
Individual trauma is an event that occurs to one
person.
Single event
Multiple events occurring simultaneously
Prolonged events that occur over a period of
time
13. Individual Trauma
Individual trauma does not just affect the individual, it affects
people who are close to the survivor.
They experience the emotional repercussions of the event
Recounting what they said to the person before the event
React in disbelief or denial
Thoughts of it could have happened to them, or will happen to them.
Sometimes they blame the victim.
14. Individual Trauma
Individual survivors may not receive the same support and concern
that members of a group trauma will receive.
Less Likely to reveal their traumas
They receive less validation of their experiences
Shame distorts their perception of responsibility for the trauma
Those who have kept the trauma secrete do not get support
Receive no comfort and acceptance from others
Struggle with causation
Feel isolated
Experience repeated trauma which makes them feel victimized
15. Physical Trauma
Physical injury is the most prevalent of all individual traumas
70% of ER cases are people under the age of 45 (McCaig &Burt, 2005)
Physical injuries have significant psychological impact, especially if they
are disfiguring
Excessive alcohol use is the leading factor for physical injuries (50% of
patients admitted to the ER have injuries related to alcohol use and
dependence (Gentilello et al., 2005)
2/3 of ambulatory assault victims presenting to the ER had positive
substance use tests, more then ½ of all victims had PTSD 3 months later
(Roy-Bryne et al., 2004)
16. Interpersonal Traumas
Interpersonal traumas are events that occur between people who
often know each other.
Typically these are reoccurring events.
This includes spouses, children, domestic partners, other relatives,
and room mates. It can also be by unfamiliar people as well.
Examples include physical and sexual abuse, sexual assault,
domestic violence, and elder abuse.
17. Intimate Partner Violence
Often referred to as Domestic Violence.
Pattern of actual or threatened physical, sexual, and /or emotional
abuse.
Differs from simple assault:
Multiple episodes often occur
Sustained over a period of time
Perpetrator is an intimate partner of the victim.
The client may still be in contact with and encountering abuse from
the perpetrator while in treatment.
Children are the hidden causalities of IPV
18. Children and Domestic Violence
3-4 million children between the ages of 3-17 are at risk of exposure
to domestic violence each year. (Domestic Violence Round Table, 2014)
Children who witness IPV are more likely to :
higher risks of alcohol/drug abuse, post traumatic stress disorder, and
juvenile delinquency.
Witnessing domestic violence is the single best predictor of juvenile
delinquency and adult criminality.
It is also the number one reason children run away.
19. Developmental Traumas
Developmental traumas include specific events or experiences that
occur within a given developmental stage and influence later
development, adjustment, and physical and mental health.
Can be a result from tragedies that occur outside an expected
developmental or life stage.
Can also occur from events at any point in the life cycle that create
significant loss and have life altering consequences.
These traumas are often related to adverse childhood experiences
(ACEs).
20. Adverse Childhood Experiences
Did a parent or other adult in the household often or very often…
Swear at you, insult you, put you down , or humiliate you? Or act in a
way that made you afraid that you might be physically hurt?
Did a parent or other adult in the household often or very often….
Push, grab, slap, or throw something at you? Or ever hit you so
hard that you had marks or were injured?
Did an adult or person at least 5 years or older then you ever…
Touch or fondle you or have you touch their body in a sexual
way? Or attempt or actually have oral, anal, or vaginal
intercourse with you?
21. Adverse Childhood Experiences
Did you often or very often feel that…
No one in your family loved you or thought you were important or
special? Or Your family didn’t look out for each other, feel close to
each other, or support each other?
Did you often or very often feel that…
You didn’t have enough to eat, had to wear dirty clothes, and had no
one to protect you? Or Your parents were too drunk or high to take
care of you or take you to the doctor if you needed it?
Was a biological parent ever lost to you through divorce, abandonment, or
other reason?
22. Adverse Childhood Experiences
Was your mother or stepmother:
Often or very often pushed, grabbed, slapped, or had
something thrown at her? Or sometimes, often or very often
kicked, bitten, hit with a fist, or hit with something hard? Or Ever
repeatedly hit over at least a few minutes or threatened with a gun or
knife?
Did you live with anyone who was a problem drinker or alcoholic, or who used
street drugs?
Was a household member depressed or mentally ill, or did a household
member attempt suicide?
Did a household member go to prison?
23. What does the ACE score indicate?
The higher the ACE score the greater the likelihood of:
Severe and persistent emotional problems
Health risk behaviors
Serious social problems
Adult disease and disability
High health and mental health care costs
Poor life expectancy
The following information and slides are from September 2003 Presentation at “Snowbird Conference” of the Child Trauma Treatment
Network of the Intermountain West. Vincent J. Felitti, MD and from Laniu/Vermetten Book Chapter 6/2007
24. Adverse Childhood experiences
are common
Of the over 17,000 HMO members surveyed in the Kaiser
study:
87% of the people reported at least one ACE
10.6% had experienced emotional abuse
28.3% had experienced physical abuse
20.7% had experienced sexual abuse
14.8% had experience emotional neglect
Adverse Childhood Experience Study. Wikipedia. Retrieval date November 18, 2014 from
http://en.Wikipedia.org/wiki/Adverse_Childhood_Expereinces_Study
25. ACE continued…..
9.9% had experience physical neglect
12.7% witnessed domestic violence
26.9% had someone in the household with a
substance abuse issue.
19.4% lived in a household where a member had a
mental illness
23.3% experienced parental separation or divorce
4.7% had an incarcerated household member.
1 in 16 was exposed to 4 categories. 66% of the
women experienced abuse, violence or family strife in
childhood
Adverse Childhood Experience Study. Wikipedia. Retrieval date November 18, 2014 from
http://en.Wikipedia.org/wiki/Adverse_Childhood_Expereinces_Study
26. Prevalence of ACE’s in the KP study
http://acestoohigh.com/got-your-ace-score/
27. The number of ACE’s is associated
with adulthood high risk behavior
36. Group Trauma
Group trauma is a traumatic experience that affects a particular
group of people.
The group shares a common identity or history as well as similar
activities and concerns.
First responders
Families and co-workers
Gang members
Firefighters
Military members in a specific theater of operation
37. Mass trauma
Mass traumas affect large numbers of people either directly or
indirectly
Involve significant loss of property and lives as well as wide spread
disruption of normal routines and services.
These events typically exceed the capacity of the affected
community.
This type of event usually causes compound trauma, or multiple
traumas
38. Community or Cultural Trauma
This type of trauma can cover a wide range of violence and
atrocities.
It may involve violence
Rape
Hate crimes
Gang related violence
Mass shootings (schools, work places, recreational venues)
It includes actions that attempt to dismantle systemic cultural
practices, resources and identities.
Boarding schools for Native Americans
Japanese internment camps
LGBT community being casted out, ridiculed, or victimized
39. Historical Trauma
Also known as Generational Trauma
Events are so wide spread the effect the entire culture
The events are so intense they can influence generations of the
culture beyond those that experienced them directly.
African American enslavement, torture, and lynching's
American Natives forced onto reservations, mass murders, and forced assimilation into mainstream culture.
Extermination of millions of Jewish people during WWII
Genocide of people in Rwanda and Cambodia
Research suggests that historical trauma has repercussions across
generations
Depression
Grief
Domestic Violence
Substance abuse
Significant loss of cultural knowledge, language, and history
40. Political Terror and war
Political terror and war threaten the existence, beliefs, well being, or
livelihood of a community and is likely to be experienced as
traumatic by community members.
Terrorism is a unique subtype of human caused disasters
The goal is to maximize uncertainty, anxiety and fear
Response are often epidemic and effect large numbers of people who
have direct and indirect exposure
Terrorism has responses not common to other disasters
Reminders of the unpredictability of terrorists acts
Increase in security measures for the general population
Intensified suspicion about a specific population
Heightened awareness over large scale populations
41. Refugees
Worldwide there are 12 million refugees and asylum seekers
(SAMHSA, 2014)
21 million internally displaced people
35 million uprooted people (USCRI, 2006)
Most of these people have survived horrendous ordeals with
profound and lasting effects on the population
Witness deaths by execution, starvation, and beatings. Many have
experience horrific torture
They will also have adjustment related difficulties in their new
country
42. System Oriented Traumas
What is a system oriented trauma?
Re-traumatization occurs when clients experience
something that makes them feel as though they are
undergoing another trauma.
Agencies that adjust their policy and procedure to remain
sensitive to the needs of the individual who has undergone
trauma are more likely to have success in providing care,
retaining clients, and achieving outcomes.
43. Examples of issues that re-
traumatize
Being unaware that the clients traumatic history affects his/her life.
Failing to screen for trauma history prior to treatment planning.
Challenging or discounting reports of abuse or other traumatic
events.
Using isolation or physical restraint
Using experiential exercises that humiliate the individual
Endorsing a confrontational approach in counseling
Allowing the abusive behavior of one client towards another to
continue without intervention.
Labeling behavior or feelings as pathological.
44. Examples of issues that re-
traumatize
Failing to provide adequate security and safety within a program.
Not providing opportunities to learn by too stringent of rules and
regulations that do not allow dignity of risk.
Limiting participation of the client in treatment decisions and
planning processes.
Minimizing, discrediting, or ignoring client responses.
Disrupting counselor-client relationships by changing counselor’s
schedules and assignments.
Obtaining urine specimens in non-private settings.
Having clients undress in the presence of others
45. Examples of issues that re-
traumatize
Inconsistently enforcing rules and allowing chaos in the treatment
environment.
Imposing agency policies or rules without exceptions or an
opportunity for clients to question them or provide input into them.
Enforcing new restrictions within the program without staff-client
communication.
Limiting access to services for ethnically diverse populations.
Accepting agency dysfunction, including lack of consistent,
competent leadership.
47. Characteristics of trauma
Objective characteristics
These are external to the individual
Characteristics of the trauma that are tangible or factual
Subjective characteristics
These are internal to the person
Characteristics of the trauma include perceptions of
traumatic experiences and meaning assigned to them.
49. Frequency of trauma
Single trauma is limited to a single
point in time
Car accident
Rape
Sudden death of a loved one
50. Frequency of trauma
Repeated trauma is a series of traumas
happening to one person over time.
Repeated sexual and physical assaults
Exposure to frequent traumas of others
They do not have to be related
traumas
51. Frequency of trauma
Sustained trauma is one that is repeated or chronic over a period of
time. This can be weeks, months or even years.
People in chronically stressful, traumatizing environments tend are
particularly susceptible to traumatic stress reactions, substance
abuse, and mental disorders
Sustained traumatic experiences tend to where down resiliency and
the ability to adapt.
Ongoing childhood sexual abuse
Physical neglect
Emotional abuse
People who are in violent relationships
People who live in chronic poverty
52. Frequency of trauma
There is a bidirectional relationship between trauma and substance
abuse and trauma and mental illness.
Abusing drugs and alcohol creates greater vulnerability to the effects of
trauma.
Abusing drugs and alcohol increases the risks of traumatic experiences
by placing a person in situations where trauma is more likely to occur
Substance use reduces the person’s ability to take corrective and
remedial action that could reduce the impact of trauma.
Likewise, traumatic stress leads to greater likelihood of substance abuse
that in turn increases the risk for additional exposure to trauma.
53. Time between events
A severe pattern of ongoing trauma (Cascading trauma) occurs
when multiple traumas happen in a pattern that does not allow an
individual to heal from one traumatic event before another one
occurs.
The available support to the individual may not be adequate, even
if there is sufficient time between events to process the event.
54. Losses the trauma has caused
Losses associated with trauma have far reaching effects
It is vital to assess the losses associated with the trauma
and what meaning it has to the individual
The number of loses significantly impacts resiliency
Without understanding the role the loss plays in the
dysfunctional behavior, the individual is at risk for
increased relapse.
55. Was the trauma expected or
unexpected?
Being unprepared, unaware and vulnerable increases the risk for
psychological injury
Some events are expected – hurricanes, trauma associated with
war, emergency workers
People with IDD, substance use disorders and mental illness are
more vulnerable.
People will attempt to regain control by replaying the events
leading up to the trauma
56. Were the effects on the persons life
isolated or pervasive?
When the trauma is isolated from the persons
life, their response to it is more likely to be
contained and limited.
People who remain in the vicinity of the trauma
may encounter greater challenges.
57. Who was responsible for the act,
and was it intentional?
Events that reflect an intention to harm could be a primary indicator
in predicting subsequent difficulties among individuals exposed to
trauma.
There is an initial disbelief that someone would intend to harm
people.
There is considerable emotional and behavioral investment into
making things right again or to make sense of a malicious act.
It is human nature to assign blame
58. Was the trauma experienced
directly or indirectly?
Trauma that happens to someone directly
seems to be more damaging then
witnessing the trauma of others.
Some situations however, experiencing
someone else's pain can be equally
traumatizing.
59. 2 ways we experience the trauma
of other people
Witness the event
Car accident happens in front of us
Seeing a terrorist act on TV like the world trade center bombing watching the
plans strike the tower.
A child watching interpersonal violence between his/her parents
Hear about the event
A friend tells you about being raped
A family member describes being in a car accident
News coverage of a natural disaster in another region.
60. Variables that affect impact the
reaction to the trauma witnessed
Proximity to the events
Witness the response of the situation
Relationship to the survivor
Degree of helplessness surrounding the
situation
Exposure to subsequent consequences.
61. What has occurred since the
traumatic event?
We must assess the degree of disruption after
the initial trauma has occurred
Response and assistance immediately after the
event. How long is that assistance maintained is
important.
The degree for disruption in resuming normal
daily activities.
63. Psychological meaning of the
Trauma
To understand the impact of trauma we have to
understand the meaning the survivor has attached to
the traumatic experience.
A persons unique interpretation of the event contributes
to how they process, react to and cope with and
recover.
What happened is not nearly as important as what the
trauma means to the individual.
People interpret events in different ways. There are many
factors that shape that interpretation.
64. Disruption of core assumptions and
beliefs
Trauma often engenders a crisis of faith that
leads the survivor to question the basic
assumptions of life.
Some survivors view themselves after the event
as damaged and beyond repair.
Surviving trauma alters a survivors perception of
them self.
65. Cultural meaning of the trauma
Professionals must consider the traumatic experience
within the context of the individuals culture.
Culture strongly influences the perception of trauma
Trauma’s that involve shame affect some cultures more
then others.
Some cultures believe that traumatic experiences are
some form of retribution from a spiritual being or the
earth.
Our perceptions of the traumatic event can be very
different then the clients based on our own culture.
67. Individual factors
Physiological factors
Psychological make up
Trauma history and resilience
Socio-demographic factors
History of mental disorders
68. Physiological factors
Genetics
Physical condition of the body
Neurological deficits
Developmental delays
Hormonal and endocrine issues
History of disease
69. Trauma History
People with histories of prior trauma appear to be more
susceptible to severe traumatic responses.
The effects of trauma are cumulative.
Trauma survivors are not always consciously aware of the
impact a trauma has had on them.
Individuals with histories of trauma can respond
negatively to treatment efforts.
70. History of Resilience
Resilience is the ability to survive and thrive despite negative
experiences and to heal from traumatic events.
Resilience is impacted by the persons internal strengths and the
environmental supports an individual has in place.
Most people are resilient to trauma and its effects.
There are many factors that impact resilience:
Neurobiology
Flexibility in adapting to change
Beliefs prior to the traumatic event
Sense of self efficacy
Ability to experience positive emotions
71. History of Mental Health Disorders
There is a connection between traumatic stress, substance abuse
disorders and co-occurring mental disorders.
Traumatic stress reactions are linked to (APA, 2013a) :
Higher rates of mood dysregulation
Substance use
Anxiety
Trauma
Stress related disorders
Each of these can precede, follow or occur concurrently with the
trauma itself.
A co-occurring mental disorder is a significant determinant of whether
an individual can successfully address and resolve trauma as it
emerges.
72. Socio-demographic factors
Gender
Men are at a higher risk of exposure to stressful events.
Women experience PTSD at a rate 2x that of men
Trauma type are different for men then women
Men’s traumas typically occur in public, women’s are more likely to
occur in private
Perpetrators against men are often strangers, women are more likely to
know their perpetrator
Children follow the same pattern as women as far as where and who
perpetrates their traumas.
(Breslau, 2002, Kimberling, Ouimette, & Weitlauf, 2007, Tolin & Foa, 2006)
73. Socio-demographic factors
Age
The older one becomes the higher the risk of trauma
Trauma that occurs in the earlier or midlife years has a greater impact
on people
Older adults and young children have greater vulnerabilities
Adults in general have a greater ability to survive without injury and a
greater ability to address the current trauma without psychological
interferences form earlier traumatic events.
Older people are naturally more likely to have a traumatic history
because they have lived longer.
74. Race, ethnicity, and culture
The potential for trauma exists in all groups in our society.
Some groups are more likely to experience specific types of trauma
(Catalano, 2004)
African Americans experience an overall higher rate of violence, aggravated
assault and robbery (Catalano, 2004)
Caucasians are more likely to experience any kind of trauma (Roberts, 2001)
Hispanics and African Americas are more likely to experience child maltreatment
and interpersonal violence (Roberts, 2001)
Historical and cultural trauma affects some groups in our country more
then others.
African Americans
Japanese Americans
Native Americans and Alaskan natives
75. Sexual Orientation
People in the LGBT community experience various forms of trauma
related to their gender identity and sexual orientation
Family consequences
Faith traditions
Higher risk for assault from sexual partners
Hate crimes
Lack of legal protection
Laws of exclusion
Gay and bisexual men are more likely to be victimized than lesbian and
bisexual women. (Dillon, 2001)
Dillon further found that trauma exposure among the LGBT community
is 94%. 40% of responders in his research reported harassment for their
sexual orientation. (Dillon, 2001)
Heterosexual women are at a greater risk for being physically and
sexually abused then homosexual women. (Dillon, 2001)
76. Homelessness
It is estimated that up to 2.5 million people in the US are homeless on
any given day. (United Nations Commission on Human Rights, 2005)
1.37 million of the total homeless population in USA are children
under the age of 18. 40% are families with children, 41% are single
males, 14% are single females. (United Nations Commission on Human Rights, 2005)
40% of the men that are homeless are Veterans (National Coalition for the
Homeless, 2002)
76 to 100% of the women who are homeless have trauma symptoms
(SAMHSA, 2014)
The most prevalent diagnosis behind substance abuse issues for this
population is PTSD.
Women and children who are homeless report having experienced
sexual assault and abuse prior to becoming homeless
77. “You never change things by
fighting existing reality. To
change something, build a new
model that makes the old
model obsolete”
BUCKMINSTER FULLER
79. References
Adverse Childhood Experience Study. Wikipedia. Retrieval date November 18, 2014 from
http://en.Wikipedia.org/wiki/Adverse_Childhood_Expereinces_Study
SAMHSA, Trauma Informed Care in Behavioral Health Services, Tip 57. (2014)US Department of
Health and Human Services: Rockville, MD. Chapter 2, pp33-55.
Almazar, R. Almazar Consulting PPT Presentation. Behavioral Health is Essential to Health. Retrieval
date November 01, 2014.
Gentilello, L.M., Ebel, B.E., Wickizer,T.M., Salkever, D.S., & Rivara, F.P. (2005). Alcohol interventions
for trauma patients treated in emergency departments and hospitals: A cost benefits analysis.
Annals of Surgery., 241, 541-550
Roy-Bryne, P.P., Russo, J., Michelson, E., Zatzick, D., Pitman, R.K., & Berliner, L., (2004) Risk factors
and outcome in ambulatory assault victims presenting to the acute emergency department
setting: implications for secondary prevention studies in PTSD. Depression and Anxiety., 19, 77-84
Presentation at “Snowbird Conference” of the Child Trauma Treatment Network of the Intermountain West.
Vincent J. Felitti, MD and from Laniu/Vermetten Book Chapter 6/2007. Presentation date from September 2003.
Ace is too high. Retrieved from http://acestoohigh.com/got-your-ace-score/ on November 18, 2014.
U.S. Committee for Refugees and Immigrants. (2006) World Refugee Survey 2006: Risks and Rights. Arlington, VA:
US Committee on Refugees and Immigrants.
80. References
American Psychiatric Association. (2013a). Diagnostic and Statistical manual of mental disorders. (5th ed.).
Arlington, VA: American Psychiatric Association.
Catalano, S.M., (2004). Criminal victimization, 2003: national crime victimization survey. Washington, DC: Bureau of
Justice Statistics.
Breslau, N. (2002). Gender differences in trauma and posttraumatic stress disorder. Journal of Gender Specific
Medicine, 5, 34-40.
Kimberling, R., Ouimette, P., & Weitlauf, J.C. (2007). Gender issues in PTSD. In M.J. Friedman, T.M. Keane, &P.A.
Resick (Eds.), Handbook of PTSD: Science and practice (pp. 207-228). New York: Gilford Press.
Dillon, J.R., (2001). Internalized homophobia, attributions of blame, and psychological distress among lesbian, gay,
and bisexual trauma victims. Dissertation Abstracts International: Section B: The Sciences & Engineering, 62, 2054.
United Nations Commission on Human Rights. 2005 retrieved on November 21, 2014 from
http://www.homelessworldcup.org/content/homelessness-statistics
National Coalition for the Homeless. (2002). Why are people homeless? Washington, DC: National Coalition for the
Homeless.
Centers for Disease Control. Intimate partner Violence Definitions. Retrieved from
http://www.cdc.gov/violenceprevention/intimatepartnerviolence/definitions.html retrieval date December 2,
2014
Domestic Violence Round Table Retrieved from http://www.domesticviolenceroundtable.org/effect-on-
children.html. Retrieval date December 2, 2014
81. References
Lalor, K. and McElvaney, R. (2010)Child Sexual Abuse, links to Later Sexual Exploitation/High Risk Behavior, and
Prevention/Treatment Programs. (11), 159-177.
Dube SR, Anda RF, Felitti FJ et al. Childhood abuse, household dysfunction, and the risk of attempted suicide
throughout the lifespan: Findings from the Adverse Childhood Experiences Study. JAMA, 2001; 286:3089-3095.
