Trauma - Informed Care: Putting Humanity Back Into Human Services
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6/9/2021
Trauma - Informed Care:
Putting Humanity Back Into Human
Services
Scott Webb, MSE
Trauma-Informed Care Coordinator
Wisconsin Department Of Health Services
UW-Madison School of Medicine and Public Health
June 9, 2021
• ACEs Overview
• Trauma Overview
• Trauma and the Brain
• Trauma in the Workplace
• Trauma-Informed Care
• Building Resilience in a COVID-19
World
• Next steps
• Questions
1
6/9/2021
But first…
What is one gift
from this time that
you will keep and
hold onto?
What We Know
We Need Each Other
2
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Adverse Childhood Experiences
Source: YouTube.com
Adverse Childhood Experiences:
• are common
• are intergenerationally passed
• have a cumulative effect—the higher the score, the
higher the likelihood of health risk behaviors and
poor health outcomes
• are NOT destiny!
3
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of Wisconsin
residents have
at least 1 ACE
Findings from the 2015-2018 Behavioral Risk Factor Survey
4
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ACE distribution by race
Individuals who are AI/AN, Multiracial and Black have higher
rates of ACEs than Whites, Hispanics/Latinos, and Asians
0 ACEs Any ACE
American Indian/Alaska Native 23% 77%
Multiracial 24% 76%
Black 24% 76%
Hispanic/Latino 34% 66%
White 45% 55%
Asian 61% 39%
Findings from the 2011-2016 Behavioral Risk Factor Survey
ACEs and household income
0 ACE
43%
4+ ACEs 41%
36% 36%
24%
17% 18%
13%
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ACEs and Mental Health
50%
43%
40%
30% 29% 28%
24%
20% 16%
14% 14%
10%
10% 8% 8%
5% 5%
0%
0 ACEs 1 ACE 2-3 ACEs 4+ ACEs
Current Anxiety Frequent Mental Distress
Lifetime Depression Diagnosis
Findings from the 2017-2018 Behavioral Risk Factor Survey
ACEs and Physical Health
50%
40%
40%
32% 33%
30%
30% 26%
20% 17%
14% 15%
12%
9% 10%
10% 7%
0%
0 ACEs 1 ACE 2-3 ACEs 4+ ACEs
Asthma Fair/Poor General Health Obesity
Findings from the 2017-2018 Behavioral Risk Factor Survey
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Abuse
Specific ACEs
Emotional Abuse 30%
Physical Abuse 17%
Sexual Abuse 12%
Findings from the 2017-2018 Behavioral Risk Factor Survey
ACE score and current smoking
50%
General
40% population
32%
30%
20% 18%
13%
16%
10%
10%
0%
0 ACEs 1 ACE 2-3 ACEs 4+ ACEs
Findings from the 2017-2018 Behavioral Risk Factor Survey
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ACEs and Absenteeism
Absenteeism (>2days/month)
20%
15%
15%
12%
10% 9%
8%
6%
5%
0%
0 ACEs 1 ACE 2 ACEs 3 ACEs 4+ ACEs
Source: The Permanente Journal, 2004 Winter, 8(1): 30-38
Serious Problems Performing Job
20%
18%
15%
15%
13%
10%
10%
6%
5%
0%
0 ACEs 1 ACE 2 ACEs 3 ACEs 4 ACEs
Source: The Permanente Journal, 2004 Winter, 8(1): 30-38
8
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Trauma
• A wound
• More about the reaction than
the event
• Disease of disconnection (Judith
Herman, MD)
• Subjective
• Lives in the body
• Affects relationships
• You question your place in the
world (Trauma worldview)
Why are so many talking about trauma?
• Disclosure
• Prevalence
• Science
• Services
• Hope (How Other Possibilities Emerge)
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Father Gregory Boyle
Photo: Homeboy Industries
The Many Faces of Trauma
• Acute
• Complex
• Historical
• Sanctuary
• Vicarious
• Collective
106/9/2021
Acute Trauma
Acute Trauma
• Adult onset
• Single event
• Adequate childhood
development
Photo: Pixabay.com
Complex Trauma
• Early onset
• Multiple events
• Not time limited
• Highly invasive
• Interpersonal
• Stigmatizing (shame)
116/9/2021
Historical Trauma
• Collective and
cumulative emotional
and psychological
wounding across
generations
• Creates survivor guilt,
depression, low self-
esteem, numbing out,
and anger
Sanctuary Trauma
Wounding in settings
believed to be safe:
• Home
• Medical services
• Mental health
services
• Substance use
disorder services
• Foster care
• Schools
• Places of worship
126/9/2021
Vicarious Trauma
The experience of learning
about another person’s
trauma and experiencing
trauma-related distress as a
result of this exposure.
Collective Trauma
Collective Trauma
• Multi-layered
• Negatively
impacts entire
societies or
groups of people
• Two components:
• Inability to
escape
• Unable to
make sense
of it
136/9/2021
Collective Trauma
• A situation that elicits psychological trauma “violates
the familiar ideas and expectations about the world of
an individual or society, plunging them into a state of
extreme confusion and uncertainty”
• Examples:
• War
• Mass violence
• Genocide
• Pandemics
(Aydin, 2017)
Talk to Us…
How has collective trauma shown up in
your place of work?
• What are you seeing?
• What are you hearing?
• What are you feeling?
• What are you needing?
Drop your thoughts into the chat and we will
share
146/9/2021
29
At least half of all the adults in the U.S. have
experienced one incident that was caused by a
major traumatizing event
(Briere and Scott, 2006)
30
Ninety percent of behavioral health
consumers have been exposed to a traumatic
event; most have multiple exposures
(((Muesar, 1998)
156/9/2021
Impact of Neglect
• Eight million children world-
wide growing up in institutions
• 75 percent of child abuse in
the U.S. classified as neglect
• Harmful to the developing
brain
• Cognitive delays
• Increased risk of
psychological disorders
Trauma Disrupts Neurodevelopment
• Person experiences trauma
• Brain and body become overwhelmed; nervous
system is unable to return to equilibrium
• Trauma goes untreated; person stays in “stress
response” mode
• Cues continue to trigger trauma (e.g. loud
noises, smells, textures)
• Person reacts to trauma cues from a state of fear
166/9/2021
Brain Development
CDC
176/9/2021
Triune Brain
Illustration: The Triune Brain, by Lchunhori at English Wikipedia
Reminders or Triggers
• Lack of control • Being touched or
• Threats or feeling watched
threatened • Loud noises
• Witnessing assaults • Darkness
• Isolation • Intrusiveness
• Being told what to do • Being locked in a room
(directive approach) • Condescending looks
• Lack of privacy • Separation or loss
• Removal of clothing • Transitions or disruptions
(medical exams) in routine
• Feeling vulnerable or
rejected
186/9/2021
“The peace of mind
you deserve in the
present is held
hostage by the terror
of your past”
-Lily Burana
TRAUMA IN THE WORKPLACE
196/9/2021
Leader
Boss
Employee Engagement
Employee Engagement in the U.S.
60%
47%
50%
40%
40%
30%
20%
13%
10%
0%
Engaged Not engaged Actively disengaged
Gallup’s 2020 State of the American Workforce Report
206/9/2021
Engagement
Disengaged Workers
60%
49%
37% 37%
18%
Higher More More errors Lower job Lower
absenteeism accidents growth productivity
Gallup's 2017 State of the American Workplace report
Engagement
70%
of employees are
searching for new
jobs or watching
for openings
The main reason?
Workplace Health Survey 2020
Lack of support and
recognition
216/9/2021
Engagement
Employees who are
supervised by highly
engaged managers are
59% more likely to be
engaged than those
supervised by actively
disengaged managers.
Trauma in Organizations
• Resist change
• Resist new leadership
• Become trauma-organized
– Reactivity replaces strategy
– Us versus them mentality
– Loss of healthy communication (gossip fills the void)
– Interpersonal conflicts erupt and aren’t dealt with
226/9/2021
The Tetris Effect
“The Tetris Effect is a
metaphor for being
stuck in a pattern of
thought or behavior.
When we are looking
for something, we see
it everywhere.”
Source: The Happiness Advantage
The Tetris Effect
236/9/2021
Impact on Staff
Cognitive Social Emotional Physical
Negative Reduced Helplessness Headaches
collaboration
Pessimistic Hopelessness
Withdrawn Tense muscles
Intrusive
Depressed
thoughts
Easily angered
Black and Fatigue
Hyper vigilant
white thinking
Adopted from: Administration for Children’s Services, New York University Children’s Trauma Institute
System Level Impact
246/9/2021
Trauma Worldview
• No place is safe
• Other people are unsafe –
can’t be trusted
• My own actions, thoughts
and feelings are unsafe
• I expect crisis, danger and
loss
• I have no worth and no
abilities
BEING TRAUMA-INFORMED
256/9/2021
Empathy…The Human Connection
266/9/2021
Do No Harm
“The very first requirement in a hospital is that it
should do no harm.”
-Florence Nightingale
“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.”
-Gordon R. Hodas, MD
Over-Arching Concept
Trauma must be seen as the expectation, not
the exception, in behavioral health treatment
systems.
(Rosenberg, 2011)
276/9/2021
Being Trauma-Informed
“What’s “What “What’s
wrong with happened right with
you?” to you?” you?”
What is Trauma-Informed Care?
• Principle-based culture change process
• Acknowledges the pervasiveness of trauma
• Focused on how trauma may effect an individual’s life
and their response to support services
• Safety for all
• Atmosphere of trust
• Compassionate collaboration
• Strengths-based
• NOT the “flavor of the day”
286/9/2021
What is Trauma-Informed Care?
• Aims to avoid re-traumatization
• Appreciates many problematic
behaviors began as understandable
attempts to cope
• Strives to maximize choices for the
survivor and control over the healing
process
• Seeks to be culturally competent
• Understands each survivor in the
context of life experiences and
cultural background
Alvarez and Sloan, 2010
Re-traumatization
• A situation, attitude, interaction, or
environment that replicates the events or
dynamics of the original trauma (a trigger)
• Can be obvious, or not
• Usually unintentional
• Always hurtful
Traumatization by Ann Jennings, PhD
296/9/2021
Top Down, Bottom-Up
• Top-down approach
deal’s with a person’s
thought process
• Primary focus of
therapy
• “What is wrong with
your thinking and how
do we fix it?”
National Council for Behavioral Health, 2021
Strategies for Regulation – Top-Down
• Journaling
• Neocortex • Self-compassion
• Limbic • Mindfulness
• Reflection
• Reptilian • Healthy boundaries
• Gratitude practices
• Problem-solving
• Pause between stimulus
and action
National Council for Behavioral Health, 2021
306/9/2021
Top Down, Bottom-Up
• Bottom-Up interventions
very are effective to
address trauma
• Assumes you must first
recognize and soothe
feelings
• Need to first notice the
feeling state that triggers
the thought
• Targets the primal part of
the brain (reptilian,
limbic)
National Council for Behavioral Health, 2021
Strategies for Regulation – Bottom-Up
• Focused breathing
• Neocortex • Grounding exercises
• Limbic • Calming spaces
• Sensory and calming
• Reptilian tools
• Exercise and movement
• Music
• Visual calming exercises
• Alternative
workstations
National Council for Behavioral Health, 2021
316/9/2021
Six Key Principles to a Trauma-Informed,
Trauma-Responsive Approach
Safety Trustworthiness Peer Support
and Transparency
Collaboration and Empowerment Cultural, Historical,
Mutuality Voice and Choice and Gender Issues
326/9/2021
Value-Based Practice: Empathic
Communication
Replace de-humanizing language (judgments) :
• Manipulative
• Non-compliant
• Attention-seeking
• Frequent flyer
with…………
S.O.F.T. S.K.I.L.L.S.
• Safety
• Offer Choice
• Foster Empowerment- (home, health, purpose,
community)
• Trustworthiness
Carter,B., Riemer,D. Teaching Soft Skills With Hard Outcomes Beginning In The Classroom: Preparing
Nursing Students To Collaborate Using Trauma-Informed Skills Designed To Advance Psychiatric
Nursing. American Psychiatric Nursing Association (APNA), 2015.
336/9/2021
S.O.F.T. S.K.I.L.L.S.
• Shared power
• Kindle Hope
• Inter-professional Collaboration
• Listen to hear feelings and needs, curiosity
• Lend Compassion
• Suspend Judgment
Carter,B., Riemer,D. Teaching Soft Skills With Hard Outcomes Beginning In The Classroom: Preparing
Nursing Students To Collaborate Using Trauma-Informed Skills Designed To Advance Psychiatric
Nursing. American Psychiatric Nursing Association (APNA), 2015.
Working with People with Traumatic
Experiences
• The descriptive labels we use increases the risk
of keeping us stuck in our stories.
• When we label, we judge.
• When we judge, we lose the ability to connect
meaningfully with others.
346/9/2021
What Does TIC Look Like?
• Avoid forcing eye contact
• Be aware of your proximity
• Avoid asking too many questions
• Pace client meetings by offering breaks
(water, stretch, etc.)
• Draw upon past success
• Ask before touching or hugging
• Provide choice when possible
• Ask about the client’s goals and priorities
What Does TIC Look Like?
• During emotional times ask “How can I support you
right now?”
• When the trauma story overwhelms or leaves you
speechless, be willing to sit in supportive silence
• Provide clear information about when, where, and by
whom services will be provided
• Be prepared to repeat information many times;
repetition is commonly needed when patients are
working with an overwhelmed nervous system
356/9/2021
Responding to People in Need
Engage person, develop rapport
Provide a calm, soothing environment
Give undivided, unhurried attention
Listen to hear (Active listening)
Give as much control and choice as possible
Validate, validate, validate!
Normalize
Assist
Avoid re-traumatization
71
Suggestions
366/9/2021
Wellbeing
Four constituents of wellbeing:
– Resilience
• Rapid return to baseline equals higher levels of wellbeing
– Outlook (Positive outlook)
• Loving kindness and compassion meditation help improve brain
circuits rapidly (7 hours of training)
– Attention – A wandering mind is an unhappy mind
• 47 percent of adults’ waking life spent not paying attention to
what they are doing
– Generosity – People doing generous, altruistic behaviors
activates the brain circuits key to fostering wellbeing
Richard Davidson, Ph.D.
Resiliency
• Nature
– Forest bathing (mindful presence in nature)
– Green and blue exercise
• Aerobic exercise
• Meditation (Loving kindness and compassion
meditation)
• Gratitude and generosity
376/9/2021
Resilience
Resilience is the ability to overcome
challenges of all kinds and to bounce back
stronger, wiser, and more personally powerful.
And…a protip...it’s contagious.
Taking the Next Step
• Leader buy-in and ongoing
support
• TIC champions
• Participant involvement
• Start small, think big
• Trauma-sensitive human
resource practices
• Trauma-sensitive environment
• Strive for intentional, not
perfection
386/9/2021
In Summary…
• Be Attentive
• Listen To Hear
• Language Matters
• Your Words Have Power
• Replace Speech That Uses Labels, Jargon,
Judgments and Demands
• With Empathy, Kindness and Compassion
Final Thought…
“ Every life is a piece of art, put together with all means available
- Pierre Janet
396/9/2021
Questions?
Trauma-Informed Resources
406/9/2021
Books
Baranowsky, A. B. and Lauer, T. (2012, 2013). What Is PTSD? : 3 Steps to Healing
Trauma
Baranowsky, A. B., Gentry, J.E., and Schultz, D. F. (2005). Trauma Practice: Tools for
Stabilization and Recovery. Hogrefe & Huber Publishers.
Boyle, G. (2010). Tattoos on the Heart: The Power of Boundless Compassion. New
York: Free Press.
Burana, L. (2009). I Love a Man in Uniform: A Memoir of Love, War, and Other
Battles. New York: Weinstein Books.
Fallot, R., and Harris, M. (2001). Using Trauma Theory to Design Service Systems.
San Francisco: Jossey-Bass.
Miller, W. R. (2018). Listening Well: The Art Of Empathic Understanding. Wipf &
Stock Publishers.
Najavits, L. M. (2019). Finding Your Best Self: Recovery from Addiction, Trauma, or
Both. Guilford Press
Najavits, L. M. (2002). Seeking Safety: A Treatment Manual for PTSD and
Substance Use. Guilford Press
Books
Perry, B. (2007). The Boy Who Was Raised As A Dog. New York: Basic
Books.
Sears, M. (2010). Humanizing Health Care: Creating Cultures of
Compassion with Nonviolent Communication. A CareInAction guidebook
for professionals. Stand and Live Inc.
Sears, M. (2010). Choose Your Words: Harnessing the Power of
Compassionate Communication to Heal and Connect.
van der Kolk, B. (2014). The Body Keeps the Score. New York: Viking.
van Dernoot Lipsky, L. (2009). Trauma Stewardship: An Everyday Guide to
Caring for Self While Caring for Others. San Francisco: Berrett-Koehler
Publishers.
Wilcox, P. (2012). Trauma-Informed Treatment: The Restorative Approach.
Holyoke: NEARI Press.
416/9/2021
Videos
What Trauma Taught Me About Resilience (Charles
Hunt):
https://www.youtube.com/watch?v=3qELiw_1Ddg
Paradox of TIC- Vicky Kelley:
https://www.youtube.com/watch?v=jFdn9479U3s
Drowning in Empathy: The Cost of VT-Amy
Cunningham:
https://www.youtube.com/watch?v=ZsaorjIo1Yc
How To Manage CF in Care Giving-Patricia Smith:
https://www.youtube.com/watch?v=7keppA8XRas
Videos
The Effects of Trauma on the Brain and How it Affects
Behaviors (John Rigg):
https://www.youtube.com/watch?v=m9Pg4K1ZKws
When Time Doesn’t Heal Al Wounds-Robert Ross:
https://www.youtube.com/watch?v=dsCNuB_KBUw
Resilience in Older Adults:
http://www.aginglifecarejournal.org/resilience-in-the-
elderly/
Disenfranchised Grief:
http://www.whatsyourgrief.com/disenfranchised-grief/
426/9/2021
THANK YOU!
Scott Webb, MSE
scott.webb@dhs.wisconsin.gov
Join the Resilient Wisconsin email list
Visit https://www.dhs.wisconsin.gov/resilient/index.htm to sign up to receive email
notices for trauma-related research, resources, training opportunities, etc.
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