Transcript Slide 1

TRAUMA and RECOVERY: A SELFHELP
APPROACH
CONSUMER LEADERSHIP IN THE
SUPPORT OF PEOPLE RECOVERING
FROM TRAUMA
By David Fuller, CPRP
Florida Partners in Crisis 2011 Annual Conference and Justice
Institute
“Leading Change, Inspiring Innovation”
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Presenter
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David Fuller, CPRP
Forensic Peer Services Coordinator,
New York Association of Psychiatric Rehabilitation
As an administrator, service provider, and independent
consultant, Mr. Fuller is an agent of change, and draws on
personal experience as a consumer—and the opportunity
to overcome many challenges— to fuel his mission of
improving access to services for people who have been
affected by psychiatric diagnoses, substance abuse and use
the public mental health system; for this reason he was
called before the United States Senate Sub Committee on
Human Rights to testify on the subject of incarceration
and mental illness.
David has been a guest lecturer at the Columbia, NYU,
Hunter, and Adelphi Schools of Social Work on Trauma
and Recovery.
What is Trauma and
Why Must We Address
It?
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What is Trauma?
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Definition (NASMHPD, 2006)
–
•
The experience of violence and victimization including
sexual abuse, physical abuse, severe neglect, loss, domestic
violence and/or the witnessing of violence, terrorism or
disasters
DSM IV-TR (APA, 2000)
–
–
Person’s response involves intense fear, horror and
helplessness
Extreme stress that overwhelms the person’s capacity to
cope
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What is Trauma
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 Events/experiences that are shocking, terrifying, and/or
overwhelming to the individual.
 Results in feelings of fear, horror, helplessness
 Triggering events may include witnessing, sensory
exposure, media exposure
 What types of events are traumatic?
What is Trauma
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 Pre and Perinatal Trauma
 Single Episode Trauma
 Developmental or Complex Trauma
 Historical Trauma
Types of Trauma Resulting in Serious Mental Illness
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•
Are usually not a “single blow” event e.g. rape, natural
disaster
•
Are interpersonal in nature: intentional, prolonged,
repeated, severe
•
Occur in childhood and adolescence and may extend
over an individual’s life span
(Terr, 1991; Giller, 1999)
What does trauma do?
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 Trauma changes the way people perceive reality.
 Trauma shapes a child’s basic beliefs about identity,
world view, and spirituality.
 Using a trauma framework, the effects of trauma can
be addressed and a person can go on to lead a
“normal” life.
 Symptoms are ADAPTATIONS
Definition of Trauma
Informed Care
Mental Health Treatment that incorporates:
–
An appreciation for the high prevalence of traumatic
experiences in persons who receive mental health services
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A thorough understanding of the profound neurological,
biological, psychological and social effects of trauma and
violence on the individual
(Jennings, 2004)
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Prevalence of Trauma
Mental Health Population
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 90% of public mental health clients have been exposed
(Muesar et al., in press; Muesar et al., 1998)
 Most have multiple experiences of trauma
 34-53% report childhood sexual or physical abuse
(Kessler et al., 1995; MHA NY & NYOMH, 1995)
 43-81% report some type of victimization
Prevalence of Trauma
Mental Health Population – Adults
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 Study in South Carolina CMHC found 91% of clients
had histories of trauma (Cusack, Frueh & Brady, 2004)
 97% of homeless women with SMI have experienced
severe physical & sexual abuse – 87% experience this
abuse both in childhood and adulthood (Goodman et al, 1997)
 Majority of adults diagnosed BPD (81%) or DID (90%)
were sexually or physically abused as children
(Herman et al, 1989; Ross et al, 1990)
Prevalence of Trauma
Child Mental Health/Youth Detention Population - U.S.
• Canadian study of 187 adolescents reported 42%
had PTSD
• American study of 100 adolescent inpatients; 93%
had trauma histories and 32% had PTSD
• 70-90% incarcerated girls – sexual, physical,
emotional abuse
(DOC, 1998, Chesney & Sheldon, 1991)
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Prevalence of Trauma
Substance Abuse Population – U.S.
• Up to two-thirds of men and women in SA treatment
report childhood abuse & neglect
(SAMSHA CSAT, 2000)
• Study of male veterans in SA inpatient unit
– 77% exposed to severe childhood trauma
– 58% history of lifetime PTSD (Triffleman et al., 1995)
• 50% of women in SA treatment have history of rape
or incest
(Governor's Commission on Sexual and Domestic Violence, Commonwealth of
MA, 2006)
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Sexual Trauma and Addiction
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 208 African-American Women with histories of
crack cocaine use
 Women with history of sexual trauma (n=134)
reported being addicted to more substances than
those who had not been sexually traumatized (n=74)
 Women with trauma histories reported more prior
treatment failures than those without.
(Young & Boyd, 2000)
What does the prevalence data mean?
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•
The majority of adults and children in psychiatric
treatment settings have trauma histories as do children
and adults served in a variety of behavioral and justice
settings.
• There appears to be a strong relationship between
victimization and later offending.
(Hodas, 2004; Frueh et al, 2005; Mueser et al, 1998; Lipschitz et al, 1999;
NASMHPD, 1998)
Other Critical Trauma Correlates: The
Relationship of Childhood Trauma to Adult Health
Adverse Childhood Events (ACEs) have serious
health consequences
• Adoption of health risk behaviors as coping
mechanisms: eating disorders, smoking, substance
abuse, self harm, sexual promiscuity
• Severe medical conditions: heart disease, pulmonary
disease, liver disease, STDs, GYN cancer
• Early Death
(Felitti et al., 1998)
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Adverse Childhood Experiences Study
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 The Adverse Childhood Experiences (ACE) Study.
ACE is a decade-long and ongoing collaboration
between Kaiser Permanente’s Department of Preventive
Medicine in San Diego and the Centers for Disease
Control and Prevention
(CDC). The ACE study was designed to assess the
relationship between the childhood experiences and the
current health status and health risk behaviors of 30,000
mainly middle-class adult members of Kaiser
Permanente. To date, data have been collected from
19,000 cooperating adults.
Adverse Childhood Experiences Study
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 The study indicates that childhood abuse and
household dysfunction lead to the development—
decades later—of the chronic diseases that are the most
common causes of death and disability in this country,
including heart disease, cancer, stroke, diabetes,
skeletal fractures, chronic lung disease, and liver
disease. A strong relationship is shown between the
number of adverse childhood experiences and reports
of cigarette smoking, obesity, physical inactivity,
alcoholism, drug abuse, depression, suicide attempts,
sexual promiscuity, and sexually transmitted diseases.
Adverse Childhood Experiences Study
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Furthermore, persons who reported higher numbers of
adverse childhood experiences were much more likely to
have multiple health risk behaviors. Similarly, the more
adverse childhood experiences reported, the more likely the
person was to develop chronic and disabling illnesses.
Traditionally viewed as public health or mental health
problems, these behaviors appear to be coping mechanisms
for people who have had adverse childhood experiences,
the study found. Authors suggest the behaviors may also
reflect the effects of the adverse experiences on the
developing brain chemistry—effects that may lead to the
adoption of the coping behaviors (www.acestudy.org).
Adverse Childhood Experiences
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Recurrent and severe physical abuse
Recurrent and severe emotional abuse
Sexual abuse
• Growing up in household with:
– Alcohol or drug user
– Member being imprisoned
– Mentally ill, chronically depressed, or institutionalized
member
– Mother being treated violently
– Both biological parents absent
– Emotional or physical abuse
(Fellitti et al, 1998)
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ACE Study
• “Male child with an ACE score of 6 has a 4600%
increase in likelihood of later becoming an IV drug
user when compared to a male child with an ACE
score of 0. Might heroin be used for the relief of
profound anguish dating back to childhood
experiences? Might it be the best coping device that
an individual can find?”
(Felitti et al, 1998)
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ACE Study
• Is drug abuse self-destructive or is it a
desperate attempt at self-healing, albeit
while accepting a significant future
risk?”
(Felitti, et al, 1998)
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ACE Study
• “ Addiction is best viewed as an
understandable, unconscious, compulsive
use of psychoactive materials in response to
abnormal, prior life experiences, most of
which are concealed by shame, secrecy, and
social taboo.”
(Felitti et al, 1998)
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What does the prevalence data tell us?
• The majority of adults and children in psychiatric
treatment settings have trauma histories
• A sizable percentage of people with substance use
disorders have traumatic stress symptoms that
interfere with achieving or maintaining sobriety
• A sizable percentage of adults and children in the
prison or juvenile justice system have trauma
histories
(Hodas, 2004, Cusack et al., Mueser et al., 1998, Lipschitz et al., 1999, NASMHPD,
1998)
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What does the prevalence data
tell us?
•
Growing body of research on the relationship
between victimization and later offending
• Many people with trauma histories have
overlapping problems with mental health,
addictions, physical health, and are victims or
perpetrators of crime
• Victims of trauma are found across all systems
of care
(Hodas, 2004, Cusack et al., Muesar et al., 1998,
Lipschitz et al., 1999, NASMHPD, 1998)
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Therefore……
We need to presume the clients we
serve have a history of traumatic
stress and exercise “universal
precautions” by creating systems
of care that are trauma-informed
(Hodas, 2005)
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What you’ll see in Participants/Clients
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 Aggression and low impulse control in new
situations or with new people
 Power struggles and fear in the context of rule
enforcement
 Disengagement as means of defense
 Interpretation of safety enforcement as predatory
 “Minor” events precipitating catastrophic
reactions
What you will see in Treatment Providers
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• Often have their own traumatic histories,
•
•
•
•
including historical trauma
Seek to avoid re-experiencing their own emotions
Respond personally to others’ emotional states
Perceive behavior as personal threat or
provocation rather than as re-enactment
Perceive client’s simultaneous need for and fear of
closeness as a trigger of their own loss, rejection,
and anger
Trauma Informed
Non Trauma Informed
• Lack of education on
trauma prevalence &
“universal” precautions
• Over-diagnosis of
Schizophrenia & Bipolar
D., Conduct D. &
singular addictions
• Cursory or no trauma
assessment
• “Tradition of Toughness”
valued as best care
approach
• Recognition of high
prevalence of trauma
• Recognition of
primary and cooccurring trauma
diagnoses
• Assess for traumatic
histories & symptoms
• Recognition of culture
and practices that are
re-traumatizing
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Trauma Informed
Non Trauma Informed
• Power/control
• Keys, security uniforms,
minimized - constant
attention to culture
• Caregivers/supporters
– collaboration
• Address training
needs of staff to
improve knowledge &
sensitivity
staff demeanor, tone of
voice
• Rule enforcers –
compliance
• “Patient-blaming” as
fallback position without
training
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Trauma Informed
Non Trauma Informed
• Staff understand function
• Behavior seen as
of behavior (rage,
repetition-compulsion,
self-injury)
• Objective, neutral
language
• Transparent systems
open to outside parties
intentionally provocative
• Labeling language:
manipulative, needy,
“attention-seeking”
• Closed system –
advocates discouraged
(Fallout & Harris, 2002; Cook et al., 2002, Ford, 2003, Cusack et al., Jennings,
1998, Prescott, 2000)
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TRAUMA INFORMED PRACTICE VS.
TRADITIONAL APPROACH
Trauma-Informed
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Traditional

Collaborative relationship


Integrated whole person
view of individual and
context
(complexity of people’s lives)
 Each system has its own view of
 “Symptoms” are seen as
coping strategies (ACE Study)
 Primary goals are
empowerment, recovery, and
self-determination (building
on strengths, expertise of
lived experience)
Hierarchical relationship
the person and his/her
“problems”
 Problems and symptoms are
synonymous
 Primary goals are stability and
absence of symptoms
FOCUS ON
TRAUMA INFORMED PRACTICE
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 Commitment and involvement from top leadership
(Champions) with a consistent message.
 Identification of a person/group responsible for ongoing training
and education of the staff and participants (Champions)
(participant’s trauma-informed bill of rights)
 Part of supervision structure
 One can’t give what they are not getting
 Principles and practice of trauma-informed apply
across the agency (at all levels, from the receptionist
to the Board of Directors)
 Part of agency plan (long-term commitment)
TRAUMA INFORMED PRACTICE
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 Includes understanding of prevalence, impact, and recovery
 Belief that recovery is possible for all
 Understands intergenerational aspect of trauma
 Focuses on “what happened” not “what’s wrong”
 Based on understanding of healing relationships (healing happens in
relationships)
 Seeks to eliminate re-victimization and re-traumatization
 Speaks to voice, choice, and control
Trauma and Recovery
A Peer Support Approach Utilizing Rational
Emotive Behavioral Therapy Methods
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What Is Needed?
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 One Peer trained in the model
 Other peers who want to participate
 A place to meet
 Manual and supporting literature (Books by Albert
Ellis)
 The ability to identify feelings or have the desire to
learn.
 Commitment
Trauma and Recovery
 Trauma profoundly changes the way we perceive
and experience life.
 One out of two American Adults experience at least
one traumatic event in their life.
 People with co-occurring mental health and
substance abuse disorders it is almost a universal
truth.
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Trauma and Recovery
 Some examples of Trauma are:
Physical, Sexual, and Emotional Abuse;
Violence, War, Homelessness, Severe Substance
Abuse, Incarceration, Restraint, Seclusion,
Poverty, Discrimination, Natural Disaster etc..
“You would be surprised at what human beings
can adapt to!” Or Do They?
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Trauma and Recovery
 Trauma responses are attitudes and
behaviors that helped people to survive
their experiences.
(hypervigilence,“antisocial behavior”)
 Mental illness, substance abuse
 Criminality
 Rational decision making has “left the
building”
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Trauma and Recovery
 Emotions are almost always in control.
 “Avoid further pain at all costs”
SO WHAT FINALLY HELPED!
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Trauma and Recovery
• Peer Support which is an evidence based
practice combined with R.E.B.T. which is one
of the original forms of modern CBT
developed by Dr. Albert Ellis
• As the word “rational” implies we will be
changing our thinking using facts to diminish
negative beliefs and feelings
• We do this by using the “ABC Paradigm”
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Trauma and Recovery
 A) is the activating event
 B) is the belief/negative self-statement
(irrational)
 C) negative emotional consequences
 D) combat with new positive/rational selfstatement
 E) new/diminished feelings
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Absolute Statements
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 Usually the negative statements that cause our
unwanted negative emotional consequences contain
words that that do not leave room for compromise.
 If we can identify these words in our self-statements
we can then begin to empower ourselves to take
some real control over our emotional state
Example
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IRRATIONAL
A) Someone moves in
front of me during rush
hour traffic
B)“People always cut
me off in traffic!”
C) Frustration, Anger
RATIONAL
D) Sometimes people
need to get in front of
me to get where they
are going.
E) annoyed, maybe
understanding
Words
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Uncompromising
Compromising
 Can’t
 Sometimes
 Won’t
 Occasionally
 Never
 Always
 All
 Every time
 Everyone
 Totally
 Some
 A Few
 From time to time
 Once in awhile
 Maybe
Trauma and Recovery
 Most “therapies” goal is to make the person
feel better but it does not fix the problem.
 REBT taught by a Credible Role Model (PEER
Support) teaches a person a concrete skill that
they can use to attempt to change the way they
think and behave. It takes action on the part of
the participant which encourages
empowerment.
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Trauma and Recovery
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 “Emotional Literacy”
 The ability to “read and comprehend” yourself
 To make sense of our “inner space” we need to be
able to attach words to our feelings so that we can
communicate our needs to others, and understand
ourselves
Trauma and Recovery
 THINGS TO REMEMBER:
 Trauma changes the way you perceive life
 The focus is safety and avoiding pain, not
being rational
 Women are usually looking to be empowered,
Men are usually looking for permission to
express their feelings
 You must start asking people what happened
to them? Not what is wrong with them.
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RESOURCES
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 The Essence of Rational Emotive Behavior
Therapy, by Albert Ellis, Ph.D. Revised, May
1994.)
 www.stopstigma.samhsa.gov/archtelpdf/PeerSu
pport_Presentation.ppt
Trauma and Recovery
For further questions please contact:
David Fuller, CPRP
[email protected]
NYAPRS
1 Columbia Place
Albany, NY 12207
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