Transcript Document

Developed for the Massachusetts Statewide Drug Court
Enhancement Project - BJA Award # 2012-DC-BX-0034
Produced by
Advocates for Human Potential
www.ahpnet.com Recovery from Trauma,
Supporting
Abuse and Exposure to Violence
JUNE 2014
Design and original materials by Niki Miller
Senior Program Associate
[email protected]
INTRODUCTION
…there are no sufficient literary,
psychological, or historical answers to
human tragedy, only moral ones. ….
Just as despair can come to one only
from other human beings, hope, too, can
be given to one only by other human
beings.
-Elie Wiesel
Our Purpose
To convey that certain difficult, inexplicable, and
even dangerous behaviors drug court clients may
exhibit, are often related to past trauma.
Not to excuse …
Not even to explain…
To prevent or eliminate problems, reduce stress,
and increase staff and client safety by using
trauma-informed approaches whenever possible.
3
If we succeed, participants will…
• Trust their good instincts, based on what they
learn about trauma-informed approaches
• View self-care & good supervision as essential
• Try out some of the techniques with clients
• Think about how their program can implement
trauma-informed practices
• Use the resource guide to learn more
4
Schedule
• Two part training with a 20 minute break
• Part 1- Impact, prevalence & relationship to
addiction / criminal behavior
• Part 2 - Effective tools and strategies; what
works and why
This training endorses & encourages participant self-care!
5
PART 1 : UNDERSTANDING TRAUMA
AND ITS IMPACT
Our brains are sculpted by our early
experiences. Trauma is a chisel that
shapes a brain to contend with strife, but
at the cost of deep, enduring wounds.
Teicher, 2000
In this segment we will:
1. Define trauma
2. Learn about the impact of trauma
3. Recognize responses that result from past trauma
4. Review trauma-informed
principles/care/approaches
7
Why learn about trauma?
Job Performance
–
–
–
–
Cost savings – crisis and ongoing care
Less effort, more results, lower recidivism
Treatment engagement, less resistance
Fewer health risk behaviors; healthier clients
Job Satisfaction
–
–
–
–
More humane communication
Fewer violent and dangerous critical incidents
Healthier staff - reduced stress and burnout
Increased staff and client safety.
8
Results of Implementation
Observations of ways clients respond:
a. Noticed a recent client knew the court was a safe place,
and displayed no resistance
b. When the team has information, clients are relieved that
they don’t have to keep repeating their story
a. Now, clients tell the team they need a respite, before
behavior accelerates, so teams can diffuse the situation.
b. Report noticeable improvements for women: They do
well in treatment.
9
MA Drug Court Staff
“The most humbling part
of drug court is seeing the
resiliency of spirit and
watching them
reclaim their lives.”
10
What do we mean by Trauma?
A state of extreme stress brought on by conditions, or
by shocking, unexpected events, that overwhelm a
person’s capacity to cope — resulting in feelings of
helplessness, terror and violation.
• The individual’s capacity to cope is so seriously
overwhelmed that they experience complete
powerlessness and loss of control
• An event may be witnessed or experienced as a threat to
survival, or an intolerable violation of self or a loved one.
May be experienced or witnessed
Potentially traumatic exposures
Childhood
Physical/mental/sexual abuse
Neglect, abandonment
Parental loss /separation
Single Event
Natural or man-made disaster
Plane/train crash
Gun violence, shooting
War
Witnessing atrocities or killing
Combat and injury
Torture
Interpersonal
Intimate partner violence
Abduction/stalking
Sexual assault/rape
Physical assault
Hate crimes
Robbery/mugging
Ongoing or lifelong
Oppression/discrimination
Genocide
Community violence
Enslavement
12
High-risk exposures resulting from addiction
People with drug and alcohol addiction
• Homelessness
• Prostitution
• Witnessing or experiencing
overdose
• Car accidents/Injuries
• IV drug use, withdrawal, DT’s,
convulsions
• Institutional seclusion &
restraint
• Stigma, social isolation, loss
of family
• Having close friends that
die suddenly
• Imprisonment, forced
institutionalization
13
How has this affected your life?
When people are dealing with the
ongoing effects of trauma, the present
can become more painful than the past.
14
Trauma memory
“There is evidence that trauma is stored in the part of
the brain called the limbic system, which processes
emotions and sensations, but not language or speech.
For this reason, people who have been traumatized
may live with implicit memories of terror, anger, and
sadness generated by the trauma, but with few or no
explicit memories to explain the feelings.”
• Sidran Traumatic Stress Foundation
15
Pam’s Story
When I was on probation, I had to go to a group for drug offenders. I really dreaded it.
Didn’t say a word, took off as soon as it was over, missed as many groups as I could. The
counselor said I was resistant and refused to participate. I had no idea why I hated it, until I
learned about triggers. There was another woman in the group, and six or seven guys. Four
of them wore leather jackets. The smell of leather was what made me want to run, and the
noises it made when they moved.
When I was 15, I cut school for the first time, to meet up with some guy I met at a party at
my older brother’s dorm. He promised me a ride on the back of his bike. We took off on his
motorcycle and rode way out of town, down winding country roads that got narrower and
bumpier, as tobacco fields rose up on both sides. Then, he pulled off the road , drove up on
the grass, about a mile deep into a field. As soon as we slowed down, four or five bikers
came out from behind a patch of trees.
They left me there in the field after they raped me. When I got up it was dark . I walked for
hours, until dawn and I hid in the garage next door till I saw my dad leave for work. Then, I
crawled in a window. No one even noticed I was gone.
When I got into the drug court program, I wanted to stop using. I didn’t know why I shut
down . I don’t think I remembered any of it until I was almost a year sober.
16
Traumatic Events & PTSD
Percentage exposed who develop PTSD
(Bloom, 2011)
Rape
49.0%
Severe beating
31.9%
Other sexual assault
23.7%
Serious accident or injury
16.8%
Shooting or stabbing
15.4%
Child's life-threatening illness
14.3%
Sudden death of a close friend…
Witness killing or serious injury
Natural disaster
10.4%
7.3%
3.8%
17
Drug Courts in Massachusetts
A juror remembers his own childhood abuse when he is called
for jury duty on a child abuse case.
An inmate with poor coping skills can’t tolerate sitting for hours
and waiting. As soon as bail is granted, his behavior escalates.
A female inmate becomes highly reactive to males and sees
every man as her father.
Staff observe incidents of self-harm and witness violence.
A client is startled when he gets a small pat on the back from a
staff member, and can’t tolerate being touched.
18
Pam’s trauma-informed story
At the initial intake with Pam, I did a standard screening for domestic
violence and current safety. She had a history, so we put together a safety
plan. Pam was distrustful and reluctant to say much.
We do not screen for trauma at intake, but assume women need single
gender groups. Pam started in a women’s group that focused on safety
and learning new coping skills. She did well and built up a little trust.
After her 3rd group, Pam and a peer asked to talk with me. Pam was crying
and had disclosed her memory of a sexual assault to a peer. I reassured
her that many women in early recovery have recalled similar experiences,
and let her know how deeply sorry I was that she had to go through that. I
reminded her that she had tremendous strength to have endured. I let her
know that she had choices now, and asked if she wanted to schedule time
with me the following day to look at some options that might be helpful.
19
Trauma-informed approaches
Screening and
referral
Screens ask about
event history,
current functioning
or current safety
Does screening
result in benefit to
client; who should
screen and when?
Partners for referral
to trauma-specific
services
Universal measures
Applied when a group
shares the same
general risk
Applied without prior
screening when the
entire group can
benefit
Universal measures
are harmless to those
without trauma, so
screening is not
required.
Integrated
treatments
Interventions that
target more than one
issue; trauma +
substance use
Some cognitivebehavioral groups
help with both;
sometimes benefit
clients w/depression
or other mental
health issues as well
Some also address
criminal thinking
20
Trauma & Mental Health
Characteristics of events that can lead to mental health problems:
• Begin in childhood or adolescence, during a critical
developmental period.
• Victimization by a trusted person; betrayal that invokes deep
mistrust.
• Intentional, prolonged, repeated or severe; involving
interpersonal violence.
• Involve physical violation, and are sexually invasive or assaultive.
21
The body responds to the brain’s signals
When a threat is perceived…
• Heart rate and respiration increase, preparing
the body for a survival response.
• Blood flows out of the thinking centers of the
brain and into the limbs to get them ready to
run.
• Pupils dilate for better night vision; hearing is
sharpened.
• Pain and hunger are temporarily dulled.
22
Trauma & The Brain: Cognition and Emotion
Cortex- logical thinking
and decision making
Slower
than
normal
Sensory Thalamus
Hippocampus
puts stimuli
in context from
past experience
Faster than
normal
Very Fast
Slower
Amygdala
wider than
normal
Response
Response
Trigger
Cortisol
(LeDoux, 1996, Bassuk 2007)
Adrenaline
Changes in arousal, attention, perception and emotion
Arousal: Extreme excitability and responsiveness or numbing and detachment
Hyper Arousal
Numbing
Attention: Inattentive, blocking out triggers or deeply focused upon them
Dissociation
Hyper-focus
Perception: Vision and hearing are sharpened or thinking is clouded and dull
Heightened
Dulled
Emotion: Feelings are devastating and painful or detached from experiences
Overwhelming
Absent
Trauma, cognitive development and health
Impact of chronic hyper-arousal:
• Can affect the architecture, development, and
functioning of the brain.
• Chronic exposure to stress hormones increases the
risk of health problems.
• Profound impact on belief system.
25
What is Post-traumatic Stress Disorder ?
An anxiety disorder people can develop after seeing or
living through a terrifying event, extreme abuse, or
exposure violence and other horrendous conditions
Most people exposed to danger and violence do not
develop PTSD; they are affected, but only temporarily.
Acute Stress Disorder: after a stressful event—a serious
automobile accident, for example—for about a month.
26
Risk factors increase
the likelihood of serious problems
Before
During
After
• Past abuse or victimization
• Few resources or supports; social isolation
• Seeing others hurt or killed or being injured
• Prolonged or repeated abuse; multiple types
• Being cut off from support; stigma
• Added stress such as loss of job or home
27
PTSD: 3 major symptom types;
plus added diagnostic criteria
Avoidance
Suppression
of
memories
Restriction of
daily activities
Substance use
Intrusion
Arousal
Startle reflex
Flashbacks
Irritability
Negative
changes in
thinking and
mood
Nightmares
Hyper-vigilance
Re-enactment
Sleep
disturbance
Changes in
arousal and
reactivity
28
Resilience factors
reduce the risk of lasting harm
During
After
• Protecting others during the event
• Feeling good about acting despite the danger
• Finding a way of coping and getting through
• Having support from friends, family or a group
• Finding a way to make meaning or learn from the
experience
29
Cultural trauma, disparities & healing
Disparities limit access to services and supports in
the communities most impacted by violence…
Protective factors are also limited.
African American and Latino youth are more than 7x
more likely to have someone close to them murdered
than their white counterparts (Finkelhor et al, 2005)
30
Adverse Childhood Experience Study
Abuse and household dysfunction seen by participants (17, 421 participants)
Types of abuse (by category)
Sexual (by anyone)
22%
Psychological (by parents)
11%
Physical (by parents)
11%
Types of household dysfunction (by category)
Substance abuse
26%
Mental illness
19%
Mother treated violently
13%
Imprisoned household mother
3%
31
ACE effects on women and substances:
• Women with 4 or more types of childhood trauma had
a 78% attributable risk for IV drug use.
• Women who did not experience any of these instances
had a .05% attributable risk for IV drug use.
• Women with histories of childhood sexual abuse were
60% more likely to abuse alcohol and 70% more likely to
use illegal drugs.
• They were also most likely to experience further abuse.
32
ACE effects-men, addiction & alcoholism
More on page 26 of your resource guide
• A male child who experienced at least 6 types of
adverse childhood experiences was 4,600% more likely
to become an IV drug user
• Self-acknowledged alcoholism in men and women
increased 500% in relation to adverse childhood
experiences.
33
ACE events data for youth referred to
Massachusetts Juvenile Court Clinics
• Six month data collected from 10/2/12 to 3/31/13
• ACE Score from 1 to 10 possible
Original CDC
Study Sample
Median
Score:
1
MA. Juvenile
Justice Sample
Median
Score:
5
Proportion
scoring 4+
6.2 %
Proportion
scoring 4+
63 %
Source: Massachusetts Alliance of Juvenile Court Clinics data report 2013
34
Both female & male drug court clients may have
trauma histories
Females
Top exposure: -- childhood sexual abuse
PTSD after exposure more likely - 20%
Males
-- witness to a killing or serious assault
Exposure more likely, PTSD less likely – 8%
About half use substances, and are less likely to More likely to use alcohol in response to the
use alcohol
effects of trauma
Repeated sexual/violent victimization from
intimates beginning in childhood
Violence from strangers/enemies; sexual
coercion/abuse in outside community
More likely to have complex PTSD and
accompanying depression
Most common additional diagnosis is
depression; not as common as in women
(Miller and Najavits, 2011)
Substances, trauma and court involvement
Childhood
violent/sexual
abuse
Mental health
consequences
Vulnerability to
violence
Coping,
surviving,
running away
Self-medication
leads to
addiction
36
Trauma-Informed Principles
1.
Trauma recovery encompasses multiple aspects of peoples’ lives,
involves changing deep beliefs and gaining knowledge and skills.
2.
The assumption of a trauma history guides every encounter, whether
or not the participants disclose or even remember trauma.
3.
Responses are reframed as survival strategies that served a safety
function and are seen as evidence of strength and resiliency.
4.
Creating safety is a primary task: the safer and more predictable the
environment, the better the engagement.
5.
Education and information about trauma is part of treatment.
6.
Power sharing is the basis of helping relationships that are founded
on respect, information, connection, and hope.
37
Preliminary Goals:  Do no harm
Increase safety
Trauma-informed approaches can decrease the risk of:
1. Staff burn-out and stress
2. Low program engagement
3. Inaccurate mental health diagnoses
4. Relapses into substance use
5. Depression and suicide risk
6. Decreased self-efficacy; learned hopelessness
38
Exercise: Self-Care Check-In
Trauma-informed approaches highlight self-care and safety for clients
and staff — beginning with you.
• Working with people with trauma histories can take a toll on
caregivers (secondary or vicarious trauma or compassion fatigue).
• It is normal to have strong feelings when people disclose histories
of abuse or exposure to violence.
• When we listen to stories about past trauma, or encounter
workplace situations that feel overwhelming, we need to find
ways to counteract stress and safeguard against burn out.
• Support, supervision and a sense of meaning make workplace
stress more tolerable, but self-care is about escape, rest and fun!
39
20 MINUTE BREAK
PART 2: IMPLEMENTING TRAUMAINFORMED APPROACHES
“Is intravenous drug use properly viewed as
a personal solution to problems that are
well concealed by social niceties and
taboo? Is drug abuse self-destructive or is
it a desperate attempt at self-healing…the
best coping device that an individual can
find?”
~Vincent Feletti, MD
ACE Study
In this segment we will:
1. Discuss risks for people working with trauma
survivors and self-care for staff & clients
2. Look at ways trauma-informed principles could
be implemented in drug courts
3. Learn more about trauma recovery
42
Trauma and the impact on staff
More on page 27 of your resource guide
Helping professionals can go through changes as a result of
empathic engagement with trauma survivors. This is sometimes
called vicarious trauma because changes may parallel trauma
responses:
• Intrusive or obsessive thoughts or difficult emotions
• Feeling over-responsible; overworking
• Physical health problems
• Feelings of distrust or excessive concern for loved ones
• Loss of hope or a diminished sense of control over one’s fate
• Over-identification or disconnectedness, callousness and
anger are common.
43
Self-Care: Model it, live it and teach it!
• Take breaks or rotate job duties
• Make time for supervision
• Find meaning
• Support from co-workers and outside support
ESCAPE! REST! FUN!
For an excellent free online course on preventing secondary trauma
from the Headington Institute visit: http://www.headington-institute.org/
44
Resources: For help with vicarious trauma
Contact your Employee Assistance Program or
ask your family doctor.
Others who can help:
•
•
•
•
•
Family services, social agencies, or clergy
Peer support groups
Health maintenance organizations
Community mental health centers
Social workers, counselors
45
Self-Care Exercise
Sample Self-Care Plan: If I become exhausted,
emotional, numb or angry:
I can talk to __________ about my feelings.
I can take a break.
I can stretch or exercise or go for a walk.
I can eat something nutritious.
I can eat something not so nutritious (chocolate!)
I can think of some of the successful clients I have helped.
I can take a nap or lie down.
I can watch something funny or entertaining.
I can play with my pet or my children.
I can shoot baskets or play another sport.
46
Establishing Safety: The key to progress
Survivors may experience intense fear even when there is
no threat to their safety or become numb or frozen in the
face of clear and present danger.
• The perception of threat and danger even when none
exists makes defensive responses likely. It is important
to address client safety if defensive actions seem
imminent, whenever possible.
47
When small adjustments = big gains
• Texting reminders of appointment has helped clients when memory
has been affected.
• Judges have opted to address inappropriate behavior in a sidebar
with the attorney instead of publically sanctioning a client with PTSD.
• A judge stepped down from the bench to preside, upon realizing
veterans were agitated when they had to face the front with their
backs to the door. This allowed them have one side toward the exit
when they spoke with the judge.
•
A client with mental health issues and problems with authority
wanted someone to listen to him when he was in lockup. The court
officer knew it would go better if he sent in a non-uniformed staff.
48
Trauma and criminal behavior
• Emotional numbing can predispose survivors to
thrill-seeking behavior, disregard for their own
safety, difficulty empathizing with others, and can
support criminal thinking.
• Let’s hear an explanation from a veteran from
About Face, online conversations about trauma and
recovery from the VA National Center on PTSD.
49
Trauma Stabilization
Trauma stabilization tools
Grounding
Selfsoothing
Self-care
Strengthbased
50
Trauma Stabilization: Grounding
Grounding directs attention to the here-and-now
and uses the senses as an anchor to the present
“I could feel myself starting to get crazy. I could feel a scream
coming up my chest and into my throat. My fists were
clenched. I began grounding. I counted the trees outside that
lined the street. Then I counted how many colors were on
each tree. Eventually, I wasn’t so pissed off. I realized my
anger was way too big for such a small thing.”
51
Trauma Stabilization: Self-Soothing
Self-soothing prepares and teaches comforting and
calming procedures before a triggered response:
“I made the list to share in group of things that make me feel
good: my daughter; my dog; riding my motorcycle; fishing;
shopping for fishing rods and tackle and eating outside. The
best thing for staff to do when I am agitated is to remind me
how much I love my kid and about what we did the last time
she visited.”
52
Trauma Stabilization: Self-Care
Self-care is learning to self-monitor emotional
states, to evaluate choices and actions, and
actively pursue emotional, mental, and physical
healing.
“I decided that I am not going to watch movies that have
violence or rape scenes. I was watching Law and Order
Special Victim’s Unit every week. I noticed I couldn’t sleep on
those nights, and I felt depressed. I like the show, but right
now I am not going to watch it.”
53
Trauma Stabilization: Strength-Based
Strength-based approaches build self-efficacy by
pointing out success, reinforcing the ability to
change and to assert control over thinking and
behavior.
“I never thought I could control myself when someone got in
my face like that. But, you’re right, I did it for years around my
stepfather. Even when I was 8 or 9 years old, I wanted to kill
him every time he hit my mom. But, I had to control myself, and
I guess the practice I got is helping now that I’m sober.”
54
Eliminating or reducing triggers
Work with each client to answer the following
questions:
• What kinds of reminders are difficult to deal with?
• What helps you calm down when you are triggered?
• What are the things staff can do to help when you
are reacting to a trigger?
55
PEACE: An approach to avoidable triggers
Predict and prepare: “When we go to court, your
husband will be in the room. Tell me what steps would
make you feel safest in court... What would you like to do
to take care of yourself afterward?”
Enlist: “What has helped you in the past not to drink when
you had to deal with your mother yelling at your kids?”
56
Acknowledge: “Many people have difficulty sleeping in
early recovery. I can understand why it makes you anxious. I
probably would not be able to sleep easily either, if I were
dealing with a lot of changes.”
Choice and control: “We ask each person to provide
a urine sample. Would you like to go take care of it now, or
would you rather come and get me when you are ready?”
Explain: “We have to put everyone through the metal
detector, even attorneys. We can make sure no weapons are
in the building. It makes everyone safer. “
(Miller, 2010)
57
Sanctions and Rewards
Research on sanctions tells us incentives are more effective at
shaping behavior. BJA recommends incentives/rewards outnumber
sanctions.
Components of effective sanctions: certainty; speed; graduated progressively more intense; and drug court clients understand the
result of each violation or achievement.
But, some sanctions can remind survivors of past punitive abuse, and
this can derail their effectiveness.
• Rewards and sanctions, developed with trauma in mind
• Observe how clients respond to sanctions
• Increase the role of incentives.
58
RICH: Respect and Information
This model states these elements form the basis for all
trauma-informed communication:
Respect: This may be a very different response than
expected. It can be challenging to convey respect
consistently. Clients may view staff and authority through
the lens of past abuse from neglectful mothers and abusive
fathers.
Information: Let clients know what is going to happen and
why. Provide education on the relationship between trauma
and substance use and how others have successfully
overcome the effects of trauma.
59
RICH: Connection and Hope
Connection: With the here-and-now and connections with
people, as well as internal connections; between the mind,
body and spirit, between actions and values. Safe
connections with others re-write the patterns of abuse
within relationships and ground survivors in today.
Hope: Remind clients that they have many strengths, have
survived many things. Recount their recent successes, small
victories and strengths. The successes of others in recovery
helps sustain hope for staff and clients alike.
60
Giving voice to survivors
“The more proactive we become by asking
what helps and what makes things worse in
times of crises, the greater opportunity we
have to align with clients in their healing.”
- Laura Prescott (Prescott et al, in press)
61
Judith Herman’s Stages of Recovery
Stages of Trauma Recovery
Establishing Safety
Remembrance & Mourning
Reconnection
Safety means….
•The survivor no longer feels completely vulnerable
•Has some confidence in the ability to protect her/himself
•Knows how to control his or her most disturbing reactions
•Knows whom to rely on for support
62
Types of trauma treatment
Past
Present
• Past - focused approaches primarily deal
with the trauma memory
• Present - focused approaches deal
with current functioning
63
Trauma & Relationships
Trauma affects the way individuals react, their relationships, and their belief
system, whether or not they have a trauma-related mental health diagnosis.
Often trauma or abuse happens in the context of a relationship. Healing also
happens through relationships.
Fairness
Consistency
Respect
Empathy
Responsibility
Honesty
Predictability
64
Trauma & Recovery: Reasons to hope
Trauma survivors in addiction recovery find their way back to
varying degrees of health through:
•
Practicing self-regulating and self-healing
•
Using the strengths and skills many already possess
•
Trying different treatment approaches at various points throughout
the course of their recovery
•
Through alternative and expressive therapies, or cultural, altruistic
and spiritual pathways
Drug court teams can offer information on effective treatment
and examples of others who are making it.
All good reasons for hope.
65