Transcript Trauma Past, Trauma Present, Trauma Future

TRAUMA-INFORMED CARE BEST-PRACTICES FOR THE
HOMELESS
Lewis “Rusty” Burger, LCSW
Family Preservation Services of VA
Providence Service Corporation
Quick Intro
• Who am I?
• Who are you?
• Goals of this session:
▫ Develop a clear understanding of Trauma-Informed
Care (TIC)
▫ Review Evidenced-Based Practices that incorporate
TIC standards for the homeless population.
▫ Review Compassion Fatigue and Secondary Trauma
for workers providing care to the homeless population.
• Quick Exercise:
• Everyone close your eyes – and point to
Montana.
• Open your eyes and look around.
• Trauma-Informed Care is a “buzz” word right
now – with many varying opinions…and with
many definitions – let’s start with a clear context
of what most experts believe TIC means.
What is Trauma?
• a traumatic event, either witnessed or experienced,
representing a fundamental threat to one’s physical
integrity or survival
• responses involve intense fear, helplessness or
horror
• the meaning of the event may be as important as
the actual physical act/experience
• what we want to emphasize is that it is an
individual's subjective experience that determines
whether an event is or is not traumatic
• http://www.lisaferentz.com/
Trauma is the experience of great ____.
• Answer – is loss!
• Loss of:
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boundaries
safety
trust
power and control
innocence
protection
attachment
possessions
consistency/predictability
sense of self/body image
U.S. Prevalence,
cont'd
One in four children/adolescents experience at least one potentially
traumatic event before the age of 16.1
In a 1995 study, 41% of middle school students in urban school
systems reported witnessing a stabbing or shooting in the previous
year.2
Four out of 10 U.S. children report witnessing violence;
8% report a lifetime prevalence of sexual assault, and 17% report
having been physically assaulted.3
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1. Costello et al. (2002). J Traum Stress;5(2):99-112.
2. Schwab-Stone et al. (1995). J Am Acad Child Adolesc
Psychiatry;34(10):1343-1352.
3. Kilpatrick et al. (2003). US Dept. Of Justice.
http://www.ncjrs.gov/pdffiles1/nij/194972.pdf.
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Exposure to Violence in Childhood
46 million of 76 million children
are exposed to violence, crime and abuse each year
Finkelhor, D., et al. (2010). Trends in childhood violence and abuse exposure:
Exposure to Violence in Childhood
• A national study of adult “foster care alumni” found
higher rates of PTSD (21%) compared with the
general population (4.5%). This was higher than
rates of PTSD in American war veterans.1
• Nearly 80% of abused children face at least one
mental health challenge by age 21.2
Statement on Homelessness
• Traumatic Stress and Homelessness
• “Homelessness deprives individuals of…basic needs, exposing
them to risky, unpredictable environments. In short,
homelessness is more than the absence of physical shelter, it
is a stress-filled, dehumanizing, dangerous circumstance in
which individuals are at high risk of being witness to or
victims of a wide range of violent events”
•
Fitzpatrick KM, LaGory ME, Ritchey FJ. Dangerous places: Exposure to violence and its mental health consequences for the homeless.
Am J Orthopsychiatry 1999; 69: 438-47.
Powerful Statistics to Review
Men
• More than 2/3 of men in a dual-diagnosis treatment program for
homeless people reported a history of trauma -- either physical or
sexual abuse.
• More than 1/4 of homeless men were assaulted in the past year.
• Homeless men within substance treatment programs have a high
prevalence of depression, family dysfunction, trauma, and multiple
previous treatment experiences.
• Despite the fact that men comprise the majority of homeless people
and are frequently exposed to trauma, homeless men are less likely to
receive social services than homeless women, with less effort directed
towards understanding the impact of trauma for this population.
Hopper, E., Bassuk E., Olivet J: Shelter from the Storm: Trauma-Informed Care in Homelessness Services Settings. Brookline, MA: The Trauma
Center at Justice Resource Institute 2005.
Powerful Statistics to Review
Women/Mothers
• Although many people think of men when they consider the issue of
homelessness, families—typically single mothers with young children—now
comprise up to 40% of the overall homeless population.
• Trauma is extremely prevalent among homeless women: over 90% of
homeless mothers report having experienced severe physical or sexual assault
during their lifetimes.
• The majority of homeless mothers were abused during childhood, with
nearly 2/3 reporting severe physical abuse and 42% reporting sexual abuse;
60% were abused before the age of twelve.
• More than 70% of homeless mothers have at least one childhood risk factor,
including: severe physical abuse, unwanted sexual contact, having a parent
who was mentally ill or who abused substances, running away for a week or
more, or being in foster care.
Hopper, E., Bassuk E., Olivet J: Shelter from the Storm: Trauma-Informed Care in Homelessness Services Settings. Brookline, MA: The Trauma
Center at Justice Resource Institute 2005.
Powerful Statistics to Review
Women/Mothers
• Homeless mothers are also frequently the victims of abuse
during adulthood, with 61% reporting a history of domestic
violence and 32% acknowledging recent domestic violence.
• Homelessness puts women at risk for assault; being homeless
was associated with more than three times the risk of sexual
assault for women.
• Homelessness and victimization are associated with adverse
mental health outcomes: more than 50% of homeless mothers
reported depression, and more than 40% reported
posttraumatic stress disorder (PTSD), and were three times as
likely as housed women to suffer from PTSD.
Hopper, E., Bassuk E., Olivet J: Shelter from the Storm: Trauma-Informed Care in Homelessness Services Settings. Brookline, MA: The
Trauma Center at Justice Resource Institute 2005.
Powerful Statistics to Review
Children and Youth
• Child abuse is associated with high-risk behaviors in adolescents,
such as truancy and running away, that may lead to homelessness.
Almost 3/4 of girls on the streets report that they were forced to run
away from violence at home.
• Homeless children and youth are at risk for further victimization,
such as repeated abuse, exposure to violence, and forced prostitution.
• 86% of homeless youth report exposure to trauma, with almost 2/3
reporting exposure to multiple traumatic events; physical assaults are
prevalent for young men, while sexual/physical abuse is common
among young women.
• Homeless children are at increased risk for medical, emotional,
behavioral, and academic problems, including post-trauma responses,
insecure attachments, and difficulty learning.
Hopper, E., Bassuk E., Olivet J: Shelter from the Storm: Trauma-Informed Care in Homelessness Services Settings. Brookline, MA: The
Trauma Center at Justice Resource Institute 2005.
Powerful Statistics to Review
Elderly
• The elderly make up a relatively lower percentage of
the homeless population, only 2%,however, elderly
homeless persons are more vulnerable to
victimization, have more health problems, and may be
less likely to receive needed social services and
protection from law enforcement.
• In 2006, 27% of the homeless victims of violent
crimes were between 50-59 years of age.
Hopper, E., Bassuk E., Olivet J: Shelter from the Storm: Trauma-Informed Care in Homelessness Services Settings. Brookline, MA: The Trauma
Center at Justice Resource Institute 2005.
Powerful Statistics to Review
Veterans
• Veterans are disproportionately represented in the homeless
population, with veterans making up 23% of all homeless people
in the U.S.
• The majority of women in homeless veteran programs have
serious trauma histories, including being physically harassed,
sexually harassed, or raped while in the military.
• One-quarter or more of homeless veterans manifest symptoms
of PTSD; 76% experience alcohol, drug, or mental health
problems.
• Trauma and related distress are related to relapse and rehospitalization of homeless veterans who have substance abuse
problems, particularly for female veterans.
Hopper, E., Bassuk E., Olivet J: Shelter from the Storm: Trauma-Informed Care in Homelessness Services Settings. Brookline, MA: The
Trauma Center at Justice Resource Institute 2005.
Powerful Statistics to Review
Minorities
• Minorities are over-represented among the
homeless population, with almost half being
African-American.
• Families of color also disproportionately
experience trauma.
Hopper, E., Bassuk E., Olivet J: Shelter from the Storm: Trauma-Informed Care in Homelessness Services Settings. Brookline, MA: The
Trauma Center at Justice Resource Institute 2005.
Powerful Statistics to Review
Lesbian, Gay, Bisexual, & Transgendered
(LGBT)Individuals
• 40% of homeless youth identify as LGBT.
• One-third of LGBT youth are assaulted after
disclosing their sexual orientation; 40% to 60% of
homeless youth cited physical abuse as a reason for
leaving home.
• Thirty-three percent of transgendered individuals
reported that they had been physically or sexually
assaulted in the past year.
Hopper, E., Bassuk E., Olivet J: Shelter from the Storm: Trauma-Informed Care in Homelessness Services Settings. Brookline, MA: The
Trauma Center at Justice Resource Institute 2005.
Discussion
Thoughts regarding these statistics?
Discussion on how Traumatic Events increase the
likelihood of someone becoming homeless.
Patterns of Violence – Review Cycle of Violence
that leads to Homelessness.
Have No fear – TIC Is Here!
Definition of TIC:
“Trauma-Informed Care is a strengths-based framework
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, and that creates opportunities for
survivors to rebuild a sense of control and empowerment.”
Hopper, E., Bassuk E., Olivet J: Shelter from the Storm: Trauma-Informed Care in Homelessness Services Settings.
Brookline, MA: The Trauma Center at Justice Resource Institute 2005.
Have No fear – TIC Is Here!
Key Components a TIC Worker will Display:
• Trauma Awareness:
▫ Will display an understanding of Trauma
▫ Staff supervision and polices will embody TIC
Standards
▫ Self-care and vicarious trauma is processed
Hopper, E., Bassuk E., Olivet J: Shelter from the Storm: Trauma-Informed Care in Homelessness
Services Settings. Brookline, MA: The Trauma Center at Justice Resource Institute 2005.
Have No fear – TIC Is Here!
Key Components a TIC Worker will Display:
• Emphasis on Safety:
▫ Will build emotional and physical safety for your
consumers.
▫ Establish clear roles and boundaries.
▫ Privacy, confidentiality, and mutual respect are
practiced.
Hopper, E., Bassuk E., Olivet J: Shelter from the Storm: Trauma-Informed Care in Homelessness Services
Settings. Brookline, MA: The Trauma Center at Justice Resource Institute 2005.
Have No fear – TIC Is Here!
Key Components a TIC Worker will Display:
• Opportunities to rebuild control:
▫ Importance of Choice
▫ Predictable Environments
▫ Efficacy and Personal Control
Hopper, E., Bassuk E., Olivet J: Shelter from the Storm: Trauma-Informed Care in Homelessness
Services Settings. Brookline, MA: The Trauma Center at Justice Resource Institute 2005.
Have No fear – TIC Is Here!
Key Components a TIC Worker will Display:
• Strengths-based approach:
▫ Not Deficit - Oriented
▫ Focus on the Future
▫ Utilization of Skill-Building (not tearing one
down).
Hopper, E., Bassuk E., Olivet J: Shelter from the Storm: Trauma-Informed Care in Homelessness
Services Settings. Brookline, MA: The Trauma Center at Justice Resource Institute 2005.
Time to Be Real
What is the culture like at your organization
toward the homeless?
How would you improve on practices of 1) Trauma
Awareness; 2) Emphasis on Safety; 3)
Opportunities to Rebuild Control; 4) StrengthsBased Approach?
Promising Models of Care for
Homelessness Organizations
• Attachment, Regulation, and Competency: A Comprehensive Framework
for Intervention with Complexly Traumatized Youth (ARC)
• Child Adult Relationship Enhancement (CARE)
• A Long Journey Home
• Phoenix Rising
• Sanctuary Model
• Using Trauma Theory to Design Service Systems
Hopper, E., Bassuk E., Olivet J: Shelter from the Storm: Trauma-Informed Care in Homelessness Services Settings. Brookline, MA:
The Trauma Center at Justice Resource Institute 2005.
TRAUMA PRESENT … KEY ELEMENTS OF TIC
Five Core Values (Fallot, 2009)
1)
2)
3)
4)
5)
Safety
Trustworthiness
Choice
Collaboration
Empowerment
WE MUST ……
Respond to the need ….
Not react to the behavior
TRAUMA AND PROFESSIONALS
Bride (2007) did a study of master’s level social workers licensed in a
southern state. The study found that…
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70.2% of workers experienced at least one symptom of STS in the
previous week
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55 % met the criteria for at least one of the core symptom clusters
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15 .2% met the core criteria for a diagnosis of PTSD.
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The intrusion criterion was endorsed by nearly half of the respondents.
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The most often reported symptoms were intrusive thoughts, avoidance of
reminders of clients, and numbing responses.
TRAUMA AND HUMAN SERVICE SYSTEMS
Who saves the hero ??
Within and between human service organizations we witness fight flight and freeze …
When we think about where this comes from … it is very similar to the experience of our
clients
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We bring in our own ACE scores
•
Our environments are stressful, demanding and sometimes abusive
• Budget Cuts
• Higher Caseloads
• Increase paperwork demands
• Higher expectations for outcomes and evidence informed practices
• Constantly changing regulations
•
Vicarious Trauma with and through our clients
CROSS SYSTEM CHALLENGES CAN ALSO BE
BECAUSE OF …
• Lack of Knowledge
• Lack of Awareness
• Lack of True Collaboration
• Lack of Resources
BECOMING A TRAUMA INFORMED
ORGANIZATION …
PREPARING OUR WORKFORCE TO OFFER
TRAUMA INFORMED PHASE ORIENTED CARE
Phase I: Safety and Stabilization
Phase 2: Trauma Reprocessing
Phase 3: Reintegration
Courtois, C., Ford, J., & M. Cloitre (2009), pp.90-100
Compassion Fatigue
Who is taking care of you ??
Mirror Neurons
Impact of Working with Victims of Trauma
• Trauma experienced while working in the role of helper has
been described as:
– Compassion fatigue
– Countertransference
– Secondary traumatic stress (STS)
– Vicarious traumatization
• Unlike other forms of job “burnout,” STS is precipitated not
by work load and institutional stress but by exposure to
clients’ trauma.
• STS can disrupt staff’s lives, feelings, personal
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relationships, and overall view of the world.
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Impact of Chronic Stress
http://www.helpguide.org/mental/stress_signs.htm
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raise blood pressure
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suppress immune system
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increase the risk of heart attack and stroke
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contribute to infertility
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speed up the aging process (life expectancy)
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create vulnerability for anxiety and depression
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obesity
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skin conditions (ex: eczema)
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sleep problems
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digestive problems
Managing Stress when working youth
• Request and expect regular supervision and supportive
consultation.
• Utilize peer support.
• Consider therapy for unresolved trauma, which the child
welfare work may be activating.
• Practice stress management through meditation, prayer,
conscious relaxation, deep breathing, and exercise.
• Develop a written plan focused on maintaining work–life
balance.
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Perry and Cost of Caring
http://childtraumaacademy.com/cost_of_caring/index
.html
Lesson 3: Self-Care Strategies for Combating Secondary Trauma
http://www.childtraumaacademy.com/cost_of_caring/lesson03/page03.html
Self-Care Strategies for Combating Secondary Trauma: An overview
Below, please find a few of the possible, positive ways you can address stress. Jot down the things you do (or will begin making a point to do) in
order to better care for yourself. List additional items within each column.
Physical
Psychological
Emotional
Workplace
Sleep well
Self-reflect
See friends
Take breaks
Eat well
Read for pleasure
Cry
Set limits
Exercise
Say "No"!
Laugh
Get peer support
Walk/Jog
Smile
Praise yourself
Get supervision
Dance
Solitude
Meditate
Use vacations
Others:
Others:
Others:
Others:
Information and slide part of Dr. Allison Sampson's Trauma Presentation
Self-Care
“Whether you and I and a few others will renew
the world some day remains to be seen.
But within ourselves we must renew it each day.”
—Hermann Hesse
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Self-care Strategies
http://www.compassionfatigue.org/pages/Top12SelfCareTips.pdf
The best strategy to address compassion
fatigue is to develop excellent self care
strategies, as well as an early warning
system that lets you know that you are
moving into the caution zone of
Compassion Fatigue.
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Self Care: Need Options
Time and Connection:
10 second exercises
2 minute exercises
5-10 minute exercises
20-30 minute GI, Walking
Meditation
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Caring For Yourself
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Self Care Apps
 Provider Resilience
 GPS for the Soul
 Mediation Oasis Apps
 Mindfulness Training System
 IChill App (Peter Levine)
 Narrative Therapy Questions (Narrative Q’s)
 Brain Wave
 http://socialwork.buffalo.edu/resources/self-care-starter-kit.html
 Flipagram (example) http://flipagram.com/f/nGbakYX6B5
 NCTSN Self Care Inventory
Provider Resilence
GPS for the Soul
“Dig where the ground is
soft” Chinese proverb
Conclusion: “Dig where the ground is soft” Chinese
proverb
Instead of picking your trickiest area, pick the issue
that you can most easily visualize improving on.
(e.g.: “making a commitment to going for a walk
every lunch time vs. getting rid of my difficult
supervisor”).
You may not notice it right away, but making one
small change to your daily routine can have
tremendous results in the long term. Imagine if you
started walking up two flights a stairs per day instead
of using the elevator, what might happen after three
months?
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Questions….
“…We are stewards not
just of those who allow us
into their lives but of our
own capacity to be
helpful...”
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10 PERCENT OF THE WORK DONE
90 PERCENT TO GO
WHAT WILL YOU DO ?
Understanding what we can do even better …
Acknowledging what we are doing now
TIC SUPPORT IN VA
WHAT IS NEXT FOR YOUR ORGANIZATION?
•
Trauma Informed approaches are a lens you can use to define the way you …
•
- Screen and Assess children and families
•
- Gather information from youth and families about the services they need and are
receiving from you
•
- Educate your workforce
•
- Make decisions about referrals to trauma informed and evidence informed programs
•
-Create safe and secure environments (physically and emotionally)
•
- Engage in Community Outreach and Partnership Building
•
- Make decisions about ongoing performance of your work, your agency and the quality of
the work you offer
• “If our aim is to nurture healthy children within
safe communities, we need to change our
approach and the values that drive our
responses to violence. The reliance on highly
punitive approaches [is] not working — they
make people more alienated and angry, they
feed cycles of revenge, and, as if that is not
enough, they are costly.”
• Dr. Lauren Abramson, Executive Director,
Community Conferencing Center, Baltimore
Together we can make a
difference
Becoming Trauma Informed is a process …
1. https://www.youtube.com/watch?v=7wK2io3Z2KM&feat
ure=em-upload_owner
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TRAUMA-INFORMED CARE BEST-PRACTICES FOR THE
HOMELESS
Lewis “Rusty” Burger, LCSW
Family Preservation Services of VA
Providence Service Corporation