OVC Provider Forum Transcript

Incorporating Trauma-Informed Care Principles Into Practice
Carole Warshaw, Gabriella Grant  -  2014/12/8
https://ovc.ncjrs.gov/ovcproviderforum
 
 
What is the best practice for interviewing a diverse population of individuals (homeless, rape and DV victims, mental illness, substance abuse) who want access to our shelter utilizing a trauma informed approach? What are the most important questions to ask?
 
1.  Carole Warshaw
 Are questions asked in trauma-informed and culturally relevant ways? Does intake and service planning reflect an understanding that trust develops over time? Do we routinely ask survivors about their children, including how they are doing, any worries they might have about their children, and any urgent concerns?
 
2.  Carole Warshaw
 Often, the first contact we have with people is during intake. In an Accessible, Culture, DV and Trauma-Informed (ACDVTI) organization, the purpose of intake is to make people feel welcomed and able to express their needs and goals for themselves and their children. This may be a fundamental shift from your agency’s current goals during the intake process. Furthermore, in an ACDVTI agency, intake procedures reflect values of flexibility and transparency, meeting people where they are and working with them to plan for their interaction with the program. In addition, staff members are trained to and do respond sensitively and appropriately when someone talks about their experiences, including current or past abuse or safety concerns.
 
3.  Gabriella Grant
 Part 3: In publicly funded homeless services, there is plentiful research showing that trauma is nearly universal, so trauma-informed practices can be implemented universally making disclosure an opportunity to make connections and, perhaps most importantly, for workers to keep an empathetic and safety-focused perspective.
 
4.  Gabriella Grant
 Part 2: To minimize some of these challenges, I recommend a 3-part approach: 1) traumatic events (the ACE questionnaire, for example), 2) trauma symptoms (Briere’s TSC-40) and 3) a list of unsafe behaviors (substance abuse, etc.). Each category is connected to trauma through research and gives people good information and 3 opportunities to “disclose” trauma. Finally, the trauma-informed model states balance universal screening with universal precautions. I use the mantra, “We ask, you do not have to tell.”
 
5.  Carole Warshaw
 It also means taking into account the traumatic effects of abuse as well as ongoing threats from an abusive partner and previous experience with systems in the ways people process information, remember details, and respond to us as providers.
 
6.  Carole Warshaw
 Creating trauma-informed services means taking time to think about how trauma might affect a person’s experience of services and what we can do to reduce further traumatization. This includes creating a physical and sensory environment that is accessible, welcoming, inclusive, healing, and attentive to potential trauma reminders (i.e. loud noises, a chaotic waiting room and for some survivors, mixed gender settings); a clinical or programmatic environment that is flexible and responsive to individual needs (and in group settings, collective needs, as well); a cultural and linguistic environment that is responsive to the people and communities being served; and a relational environment that is caring, respectful, empowering, transparent, and emotionally and physically safe.
 
7.  Gabriella Grant
 Part 1: Traditionally, asking about trauma includes a list of traumatic events and then relies on the interviewee to respond. While a step in a potentially good direction, it also presents several challenges as well. First, some people are not going to disclose. Second, some people may not recognize what happened to them as related to the specific questions. Third, as in the question, these lists are often at the beginning of a process before trustworthiness has developed. As a result, there is a frequent tension around disclosure.
 
8.  Carole Warshaw
 Understanding the range of ways we can be affected by trauma and what we can do to help counteract those experiences, mitigate their effects, and transform the conditions that produce them are key aspects of trauma-informed social justice work. The key components of a trauma-informed approach stem directly from our understanding of the impact of trauma. They reflect what people find helpful in reducing further traumatization and lead to services and environments that support survivors and their children in recovering from those effects.
 
9.  Carole Warshaw
 In many contexts (e.g., in the context of offering shelter but not counseling), it may be most relevant and in line with trauma-informed principles to focus on *providing information* about trauma and “offering* the kinds of supports that people who have experienced trauma often find useful. Although many organizations have begun asking questions about past trauma during intake, this practice must be undertaken thoughtfully, keeping in mind the context, purpose of asking, and capacity to respond. In therapeutic settings, these questions may make sense when asked in a trauma-informed manner. In other settings, providing information and creating safer spaces for people to seek support around trauma may be more helpful.
 
 
What are some specific ways in which T-I care principles are put into practice in gender-specific and culturally competent ways?
 
1.  Gabriella Grant
 Part 2: Similarly, for people identifying as men. While there has been attention and some progress on the federal level related to women (Federal Partners on Women and Trauma), we are only now starting to see a similar emphasis on men and trauma. My opinion is that we are going to have to find new and men-specific modalities to treat trauma in the male population and recognize trauma symptoms among men (violence, substance abuse) in ways that we often do not currently.
 
2.  Gabriella Grant
 Part 1: The trauma-informed principles are safety (physical and emotional), trustworthiness, choice, collaboration and empowerment. These principles allow for gender-specific approaches to focus on how, for example, people identifying as women increase their safety in ways that specifically affect women: relationships, finances, parenting, education, etc. However, the principle of choice allows me to offer a variety of services, since even within the same gender or culture, there are individual differences.
 
3.  Carole Warshaw
 One of the challenges of framing things in terms of “trauma” as opposed to abuse, violence or oppression is that one focuses on the impact on the individual (or on entire cultures or communities) and the other incorporates an understanding that there are individuals and systems that are responsible for creating these traumatic experiences. Hence the need for a more integrated trauma/social justice approach. Understanding this, in turn, highlights the need for both individual and collective responses to mitigate these risks, heal from the effects, and transform the conditions that hold them in place.
 
4.  Carole Warshaw
 as well as the insidious trauma or micro-violations of objectification, dehumanization and marginalization that many people experience on a daily basis. And, when the majority of people in a given community experience ACE (Adverse Childhood Experiences) scores of 8 or 10, then the trauma is no longer just individual, it is collective, as well and the solutions may also need to be collective When we talk about interpersonal violence, we are also talking about betrayal whether by an individual, or of the social contract. Both may also have cumulative effects and both may involve ongoing exposure and risk.
 
5.  Carole Warshaw
 As providers, we often focus on individual trauma - childhood abuse and neglect, adult or adolescent sexual assault, and abuse by an intimate or dating partner as well as the individual effects of combat trauma and military sexual assault. Yet, many people experience collective forms of trauma, as well - trauma that affects people as part of a particular community, culture, or group and - experiences that continue to affect individuals and communities across generations, for example the ongoing legacies of trauma resulting from slavery and colonization, the trauma of war, poverty, displacement and persecution, the trauma of trans/homophobic and gender-based violence as well as the insidious trauma or micro-violations of objectification, dehumanization
 
6.  Carole Warshaw
 There is a lot of work being done on TI approaches that are also gender and culturally relevant. It’s also important to remember that a lot of culturally specific and traditional healing practices are trauma informed although they may not use the language of “trauma informed,” which emerged in more recent history in the U.S. The context of gender and cultural can impact the experience of trauma. For example, in our culture, beliefs that women do not have a right to their own bodies can impact the types of violence that women experience, how women understand their experiences, and how the community responds (or doesn’t).
 
 
Does research show a relationship between trauma-informed care and recidivism for individuals who have a history of trauma and who are also involved within the criminal justice system?
 
1.  Carole Warshaw
 Part 4: This is a document produced by the New York courts evaluating the impact of speciality drug courts (which mandate and provide substance use treatment), finding them to be effective based on still-emerging research: https://www.nycourts.gov/reports/addictionrecidivism.shtml#FNT45
 
2.  Carole Warshaw
 Part 3: This article in the Scientific American summarizes some of the evidence on mental health treatment and recidivism (2014): http://www.scientificamerican.com/article/criminals-need-mental-health-care/ This document from SAMHSA’s GAINS Center for Behavioral Health and Justice Transformation, discusses how, while some mental health treatment interventions have not been effective in reducing recidivism, other treatment interventions have been successful: http://gainscenter.samhsa.gov/cms-assets/documents/141805-776469.cbt-fact-sheet---merrill-rotter.pdf This is an example of a study on the effectiveness of post-prison treatment for substance use in reducing recidivism among women (2012): http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3244804/
 
3.  Carole Warshaw
 Part 2: These conditions may underlie the reasons for their arrest, such as when a survivor of trauma who is coping by using substances is arrested on drug charges or when a survivor is coerced into using substances and engaging in other illegal activities by an abusive partner. For these individuals, both treatment and advocacy services are needed, but quality services are often unavailable in the community or during incarceration.
 
4.  Carole Warshaw
 Part 1: There is research on the high prevalence of traumatic experiences among people who are incarcerated, especially women. So of course, a trauma-informed approach is critical. We know from anecdotal evidence and research that incarceration can be retraumatizing in many ways, including the ways that people are treated in jails and prisons and the fact that many people experience physical and sexual violence while incarcerated. We also know that a lot of people who are incarcerated experience trauma-related mental health and substance use disorders.
 
5.  Markia Randle
 There is a documentary out that discusses the relationship between the criminal justice system and trauma. It follows the life of a woman who had a very traumatic childhood and a significant criminal history as a young adult. She is now a public speaker and an expert on the effects of trauma. The documentary is entitled "Healing Neen."
 
6.  Gabriella Grant
 Part 3: Obviously, reducing substance abuse and trauma symptoms can help reduce criminal activities, but good studies proving that trauma-informed interventions directly reduce recidivism are still needed.
 
7.  Gabriella Grant
 Part 2: Unfortunately, there are very few good evaluations that compare TI approaches to traditional approaches. The best one is the Women with Co-occurring Disorders and Violence Study, which was a large-scale multi-site evaluation of trauma-informed and trauma-specific practices. It found the intervention group was 31% less likely to discontinue treatment within 4 months. Substance abuse and mental health symptoms improved with increased duration of treatment, particularly for women with more severe baseline symptoms. Another study using the same data found that treatment effects were largest for subgroups characterized by high levels of PTSD.
 
8.  Gabriella Grant
 Part 1: One challenge to answering this question is that trauma-informed approaches are not easily identified, being more of a cultural shift or environmental change. Another is connecting reduction in trauma symptoms and/or substance abuse to criminal activity and recidivism. Specific treatment interventions, such as Seeking Safety, TARGET, TREM, Beyond Trauma, can be conducted and compared to a non-trauma-specific intervention. One study of women in jail receiving Seeking Safety by Saginaw County (MI) showed overall recidivism rate for successful completion of "Seeking Safety" program is 0%, felony offenses" 0% and misdemeanor offenses: 0%. Compared to the overall recidivism rate for unsuccessful completion is 17%, felony offenses: 17% and misdemeanor offenses: 0%.
 
 
Hi, could you please speak to the scope for utilization of trauma-informed care within juvenile detention and committed placement facilities?
 
1.  Gabriella Grant
 Part 3: Many organizations have been strongly recommending trauma-informed practices. Here are some resources: National Council of Juv. & Fam. Court Judges. Ten Things Every Juvenile Court Judge Should Know About Trauma and Delinquency [Ten Things], 2010 National Child Traumatic Stress Network. Blueprint for Change: A Comprehensive Model for the Identification and Treatment of Youth with Mental Health Needs in Contact with the Juvenile Justice System [Blueprint for Change]. 2007. VANDENWALLBAKE, R. Considering Childhood Trauma in the Juvenile Justice System: Guidance for Attorneys and Judges. Child Law Practice. 32, 11, 171-174, Nov. 2013.
 
2.  Gabriella Grant
 Part 2: If we look at trauma symptoms and unsafe behaviors among youth involved in juvenile justice, we see a wider range of trauma “evidence.” Again, becoming trauma-informed focuses on increasing physical and emotional safety as well as developing a variety of self-regulatory and safety skills to address real issues in the young person’s life. This is both trauma-informed and public safety related. In fact, without a trauma-informed framework, juvenile justice programs often lead to more serious criminal involvement as youth become less fearful of incarceration and exposed to older people who may perpetrate again the young person or may provide protection against perpetration in exchange for gang membership or criminal actions.
 
3.  Gabriella Grant
 Part 1: Among children involved in juvenile detention, the research shows high rates of trauma exposure and the development of PTSD symptoms. For example, 1 in 3 California youth in juvenile detention meet PTSD diagnosis vs. 1 in 9 nationally (Trauma Among Youth in the Juvenile Justice System: Critical Issues and New Directions J. Ford, et al., 2007, http://iers.umt.edu/docs/nnctcdocs/Trauma_and_Youth.pdf) However, we meet the disclosure dilemma again. Boys, youth of color and children born outside the US as well as others may not be willing to disclose trauma exposure, especially if it involved sexual abuse, parent perpetrated abuse or events where the children were made to feel responsible or guilty for what happened.
 
 
How do sessions limits work in a trauma informed care setting?
 
1.  Gabriella Grant
 Treatment for trauma benefits from a science-based, research-founded framework. The one I recommend is the neuro-sequential model by Dr. Bruce Perry. From this framework, the first course of treatment is focused on self-regulation, self-care, self-efficacy. These skills can be developed in a short-ish timeframe and can have immediate results for the individual.
 
 
Do you have any special advice on providing services to assault victims [employees or their family members] who have been involved in an incident inside of a corrections facility?
 
1.  Gabriella Grant
 In addition to general advice, including, ensuring that the person assaulted get medical attention, speak to their doctors as soon as possible, and give themselves time to physically heal, I think that the institution should assess the incident/s and make changes to how the are prioritizing employee and visitor safety. Clearly, if an employee, this is a work-related incident and the prison system has routine reports that it must complete and a risk assessment that needs to be done yearly. For the family member, additional services though Victim Witness or Victim Compensation can also be helpful (a police report is usually required).
 
 
Maybe a very basic question, but can you give me a concise "elevator pitch" to describe what is and the importance of trauma informed care? I am asked this a lot.
 
1.  Gabriella Grant
 Trauma is pervasive among populations served by publicly funded systems and many of the issues that public funding is used to address is caused by or exacerbated by trauma. Therefore, to be good stewards of the public purse, responsive to the human need for safety that we all have and to create safe and connected communities, it is essential to understand the impact of trauma and develop safety-focused programs to reduce its costly and long-term impact.
 
2.  Carole Warshaw
 • When we are able to respond in culturally resonant, trauma-sensitive, person-centered ways people feel safer disclosing, are more likely to access services, and are more likely to find services helpful. • Inquiring about abuse, making it safe for people to talk about their experiences, responding compassionately; tailoring services to individual needs and offering appropriate referrals are also critical. • Creating organizational culture that supports a compassionate, trauma-informed approach is essential
 
3.  Carole Warshaw
 • Trauma is pervasive • Trauma has significant health and mental health effects & is a leading cause of morbidity and mortality across generations • Trauma can affect people’s access to and experiences of health care. • Without an understanding of trauma services can be retraumatizing. Without an understanding of trauma, treatment may not be effective • As service providers, we are also affected by trauma and need to be supported in addressing our own feelings if we are to remain open to the experiences of the people we are serving • How we respond and the environments we create make a difference.
 
 
Does cultural diversity modify how we incorporate trauma informed care?
 
1.  Carole Warshaw
 Culturally resonant approaches also involve deep connections with the communities being served and ensuring that both the environment and approach to services are reflective of shared values and meaningful to the people being served but also individually tailored, since culture and identity may be different for each person. Openness, interest and empathy are critical to a culturally attuned approach. NCDVTMH has created a tool, Creating Accessible, Culturally Relevant, Domestic Violence and Trauma-Informed Agencies: A Self-Reflection Tool. This tool incorporates questions relevant to culturally relevancy in the context of creating TI services: http://www.nationalcenterdvtraumamh.org/publications-products/resources-for-agencies/
 
2.  Carole Warshaw
 Services that are culturally resonant and gender responsive build on the core principles of trauma-informed approach - principles that include: creating physical and emotional safety, respectful caring interactions; recognizing the challenges of building trust when trust has consistently been betrayed; sharing power, honoring mutuality and focusing on strengths; recognizing the wide range of experiences people have including the types of trauma the experience; the strengths and resources they draw on including the values, beliefs and philosophies that are sources of connection, belonging and resilience, etc.
 
3.  Gabriella Grant
 Yes, the person is the focus in a trauma-informed approach and their culture is a part of their experience. The ability to increase safety is going to be influenced by the person's culture and their connection to it. However, we are consisted with all in terms of the core values of the trauma-informed approach (safety, trustworthiness, choice. collaboration and empowerment). So, there are universal values that are individually applied and the person gets to select from the choices available what works best for him/her.
 
 
Can you recommend resources or best practice models of organizations or communities who have incorporated trauma informed care principles into practices? We are looking for organizational models and maybe examples from/or with law enforcement.
 
1.  Carole Warshaw
 There are a number of examples of successful TI approaches. One report on NCDVMTH's Multi-Site Project is available on our website http://www.nationalcenterdvtraumamh.org/wp-content/uploads/2014/09/NCDVTMH-Multi-Site-ReportRWDedits9.16CW9.17.14-rwd-final.pdf and a Promising Practices Report is forthcoming
 
 
What are some acceptable trauma informed care boundaries for frequent hotline callers?
 
1.  Carole Warshaw
 Part 2: Another critical principle here is collaboration: After communicating limitations, make decisions together about how to use limited time. Sometimes it makes sense to make a plan at the beginning of the call, asking what is most important to them to discuss. Then, check back in as the call progresses, always expressing care and interest but also openness about other demands on your time. It may also be helpful to take a moment at the end of the call to make a plan for what the person will do after the call, or if things come up for them between that and any future call to the hotline.
 
2.  Carole Warshaw
 Part 1: Helpful goals to keep in mind here are forming a genuine connection, finding out what is most important to the person to talk about, and being transparent about limitations you may be working under. A trauma-informed principle that is critical in this context is transparency. Be transparent about upcoming limitations and the reasons for limitations. For example, you may say that you need to limit your time on the phone today because a lot of lines are ringing and you need to make sure that everyone who is calling can talk to someone, especially those that are calling for the first time.
 
3.  Gabriella Grant
 Second, the use of agreements can be very helpful. It could sound like, “Gabby, we notice you have been able to rely on the hotline frequently, showing your ability to reach out and ask for help. Would it be helpful to you to develop some additional resources, so you can strengthen your network?” We have found this two-fold approach helps a lot.
 
4.  Gabriella Grant
 Part 1: This is an interesting question. First, I would recommend listening to the themes among the frequent callers. Often, there is persistent emotional overwhelm, few social connections, or precarious housing. Therefore, addressing these themes and providing resources and options for frequent callers can be helpful. For example, if people call frequently to be “talked down,” we might develop some Youtube videos with grounding instructions or have a grounding instruction available on an outgoing message that is not used.
 
 
Is there any research on the effects of physical and mechanical restraints, seclusion and strip searches on kids who have been exposed to trauma?
 
1.  Gabriella Grant
 Yes, there is tons of research. Elimination of S/R is a key goal of trauma-informed transformation. Amnesty International wrote a paper on the use of the restraint chair titles "How many more deaths" The Harvard Center for Risk Analysis, between 50 and 150 restraint- or seclusion-related deaths occur every year across the country. Plus innumerable accounts of lesser harms: injury, insults, abandonment. Just this week, a boy with autism was left alone for days in restraints. Only in the case of imminent or immediate risk of death or serious injury should any hands-on be considered and even then the agency should reflect on what happened as a treatment failure. SAMHSA has a Program Curriculum: Roadmap to Seclusion-Free and Restraint-Free Mental Health Services.
 
 
What advice can you offer an agency who works with other agencies that are not aware of T-I care and may not understand when families present as not ready to address matters during intake? For example, if investigators are asking that victims be interviewed prior to counseling, but victims are not ready to disclose.
 
1.  Gabriella Grant
 In a community, when social transformation is occurring, there tend to be leaders, followers and resisters (among others). If your agency is a leader, you may consider doing awareness activities, including conferences. You can invite speakers from other community that are, in this example, investigators, that are trauma-informed. We recently invited Dr. Vincent Felitti to speak on the Adverse Childhood Experiences Study and it really galvanized a lot of people throughout Santa Cruz to do more and engage those agencies not present.
 
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