Trauma-informed Practice (TIP) what is it? why is it important? what can you do?

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Trauma-informed Practice (TIP)what is it? why is
it important? what can you do?

• Diane Smylie
• Substance Use Knowledge Exchange Leader
• dsmylie_at_cw.bc.ca

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Background

• Provincial TIP initiative (TIP Guide
  Curriculum)
• Regional work supported by provincial KE Team
  (DTFP)
• Current work at BC Mental Health and Substance
  Use Services Children and Womens programs

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Breathe
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What? Why? How?

• Defining trauma
• Prevalence and links to health and mental health
• The rationale for trauma-informed practice
• Basic trauma-informed practice concepts and
  definitions
• TIP resources and examples of how TIP is being
  implemented in various service contexts

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Prevalence links
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Trauma and PTSD

• The terms violence, trauma, abuse, and
  post-traumatic stress disorder (PTSD) often are
  used interchangeably. One way to clarify these
  terms is to think of trauma as a response to
  violence or some other overwhelmingly negative
  experience (e.g., abuse).
• Trauma is both an event and a particular response
  to an event. The response is one of overwhelming
  fear, helplessness, or horror. PTSD is one type
  of disorder (response) that results from trauma.
  
• (Covington, 2003)

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Definition of Historical Trauma

• The cumulative emotional and psychological
  wounding across generations, including the
  lifespan, which emanates from massive group
  trauma
• When cumulative HT events are coupled with high
  rates of contemporary lifetime trauma and
  interpersonal violence, as well as high rates of
  chronic stressors, such as daily discriminatory
  events, together, these historical and
  contemporary events undermine physical,
  spiritual, and psychological health and
  well-being in complex and multifaceted ways.

Dr. Maria Yellow Horse Brave Heart, 2003
Walters et al., 2011
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Trauma is commonamong Canadians

• In a representative Canadian sample, 76.1 of
  Canadians had been exposed to at least one
  traumatic event in their lifetime, 9.2 met the
  criteria for PTSD in their life time. (Van
  Ameringen, Mancini, Patterson Boyle, 2008)

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Trauma is common among people with mental health
substance use concerns

• Majority of adults and children in inpatient
  psychiatric and substance use treatment settings
  have trauma histories (Lipschitz et al, 1999
  Suarez, 2008 Gillece, 2010)
• Survey of teens in substance use treatment gt 70
  had history of trauma exposure (Suarez, 2008)
• 2/3 adults in substance use treatment report
  child abuse and neglect (SAMHSA, CSAT, 2000)

SAMHSA, 2012
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What is Trauma?

• It can be a single event
• Often multiple events over time (complex,
  prolonged trauma)
• An interpersonal violence or violation,
  especially at the hands of an authority/trust
  figure is especially damaging
• Trauma occurs in an interaction of person by
  event by context (Harvey Tummala-Narra)

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What does trauma do to us?
Bessel A. van der Kolk , MD http//www.traumacente
r.org/products/pdf_files/Preprint_Dev_Trauma_Disor
der.pdf
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Trauma Effects
Physical Emotional or Cognitive Spiritual Interpersonal Behavioural
Unexplained chronic pain or numbness Stress-related conditions (e.g., chronic fatigue) Headaches Sleep problems Breathing problems Digestive problems Depression Anxiety Anger management Compulsive and obsessive behaviours Dissociation Being overwhelmed with memories of the trauma Difficulty concentrating, feeling distracted Fearfulness Emotionally numb/flat Loss of time and memory problems Suicidal thoughts Loss of meaning, or faith Loss of connection to self, family, culture, community, nature, a higher power Feelings of shame, guilt Self-blame Self-hate Feel completely different from others No sense of connection Feeling like a bad person Frequent conflict in relationships Lack of trust Difficulty establishing and maintaining close relationships Experiences of re-victimization Difficulty setting boundaries Substance use Difficulty enjoying time with family/friends Avoiding specific places, people, situations (e.g., driving, public places) Shoplifting Disordered eating Self-harm High-risk sexual behaviours Suicidal impulses Gambling Isolation Justice system involvement
Haskell, 2003 Haskell, 2001 Schachter et al.,
2009
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ACEs Study
Death
If not disrupted
conception
Mechanisms by which Adverse Childhood Experiences
influence Health and Well-being throughout the
lifespan
Felitti Anda, 2010
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What does this mean for healthcare
settings/providers?
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Trauma Awareness

• Consideration of the profound neurological,
  biological, psychological social effects of
  trauma violence on all of us.

For more information on the neurobiology of
trauma www.childtrauma.org
www.traumacenter.org
Margaret E. Blaustein PhD. Kristine M.
Kinniburgh LICSW
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In many cases, people who endured childhood
abuse and neglect develop what might seem like a
bewildering array of problems throughout their
lives. Many service providers, and in many
cases the survivors themselves, can misunderstand
these difficulties as self-inflicted because they
do not understand how abuse, trauma and their
effects reverberate throughout a persons life.
Haskell in Poole et al. 2012
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Issues affecting service access engagement

• Service entry points and transitions can be
  difficult to navigate
• Services often lacking coordination and
  collaboration
• Service settings and processes can be confusing
• Service providers can have a tendency to reduce
  people to labels (risky behaviors/ people)
• Services sometimes prioritize provider needs
  /routines
• Physical settings can be unwelcoming

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Trauma effects that can affect engagement

• Difficulty with trust and relationships
• Reluctance to engage and quick to drop out
• Vigilance and suspicion
• Previous traumatic experience caused by health
  care system/providers
• Ambivalence to give up or change coping
  mechanisms
• Current violence/trauma lack of agency

Harris Fallot, 2006
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What is Re-traumatization

• A situation, attitude, interaction or environment
  that replicates the events or dynamics of the
  original trauma and triggers the overwhelming
  feelings and reactions associated with them
• Can be obvious or not so obvious
• It is usually unintentional
• It is always harmful often exacerbating the
  very symptoms that people are seeking help for

Jennings, 2013 Retrieved from theannainstitute.or
g
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What about the people providing the services?
How are our values and assumptions affecting
people?
Are we sometimes overwhelmed or triggered?
How does this affect our interactions with
colleagues?
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Trauma-informed Trauma specific Practices
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Trauma-informed

• Value based with core principles
• Embed principles in all aspects of service
• Awareness of connections between trauma, mental
  health, substance use and health
• Universally offered
• Cultures of non-violence, learning and
  collaboration

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TIP Key Principles

• Trauma Awareness
• Emphases on safety and trust-worthiness (includes
  cultural safety)
• Opportunity for choice, collaboration and
  connection
• Strengths based and skill building

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Trauma specific services

• Offered in a trauma-informed environment
• Focus on treating trauma through therapeutic
  interventions
• Specialized skills
• Offered with consent to people who choose trauma
  specific treatment
• Based on a detailed assessment

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IN ACTION
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TIP can be seen in a change in the way we view
people

• Shift from What is wrong to What happened
• Change in language away from
• Controlling
• Paranoid
• Manipulative
• Uncooperative
• Attention seeking
• Drug seeking
• Not believable, etc.

Nancy Poole, 2011
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Reframing Language
From To
Controlling The individual seems to be trying to assert their power
Manipulative The individual has difficulty asking for what they want
Attention seeking The individual is trying to connect the best they can
Symptoms Adaptations
Borderline The individual is doing their best given their early experiences
Malingering The individual is seeking help in a way that feels safer
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Physical Environment

• Consider
• Signage with welcoming messages, avoiding do
  not messages
• Waiting areas - comfortable and inviting
• Lighting in outside spaces
• Accessibility and safety of washrooms
• In counselling rooms choice about whether door
  is open or closed

Fallot Harris, 2009, Ontario Guidelines, 2013
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A Story of Change

• "At first, it was hard to see if attending the
  course made much of a difference in my day to day
  work. I learned a lot but was trying to figure
  out how it would help me in an ER. While thinking
  about this, I couldn't help but see stigma
  against people with mental health AND addiction
  problems everywhere. It was like it was always
  there but I couldn't see it. The hardest part for
  me was that I couldn't not see, especially with
  colleagues that I had come to admire. The
  disapproving glances, the sighing and rolling of
  the eyes, the ignoring and running away, the
  interrupting and telling people what to say and
  do before they even had a chance to understand
  what was happening to them - the name calling -
  'bed cloggers, frequent flyers - and even 'human
  waste' is used as code. It became too much to
  handle and I was being traumatized by my
  coworkers. I took a chance and confided in
  another nurse who had also taken the CAP course
  and she felt the same. Then, we reached out to
  another CAP graduate and then we are three. We
  started to build confidence in our way of
  engaging with all people with genuine concern and
  attunement. Slowly, we became know as the
  'bleeding hearts' and we wear that badge proudly.
  When we heard about TIP, we jumped at the chance
  to be part of the appreciative inquiry and that
  even built our confidence more. You see working
  in an ER isn't so much about the patients, its
  about working around a burned out staff and
  trying to fit in."

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TIP Organizational Culture

• non-violence
• emotional intelligence
• inquiry and social learning
• democracy

• open communication
• social responsibility
• growth and change

Bloom, 2005
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Self awareness compassion for all
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Moments to Milestones Engaging with People who
use Substances 
This 30-minute video is intended as an education
resource for first responders, including police,
paramedics and emergency room staff. Also, this
video has relevance for anyone working with
people who use substances. It illustrates the
remarkable, positive difference that can be made
when people who use substance are approached in
an attuned manner that fosters respect,
compassion and inclusion.

• www.youtube.com/watch?vAHzvlMUoUYE

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Examples of whats happening in BC

• Vancouver Coastal Health TIP Champions
• BC MHSUS Childrens Womens programs
• Cross health authority MHSU dialogues
  (Jessie.MatherLingley_at_bcmhs.bc.ca if interested)
• Provincial virtual CoP site
• Appreciative inquiry with interested teams and
  groups
• MCFD is developing a supplementary TIP Guide

Funding for this event has been provided in part
by the Government of Canada, through British
Columbias Drug Treatment Funding Program -
Strengthening Substance Use Systems Initiative.
The views expressed herein do not necessarily
represent the views of the Government of Canada
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Questions?