Trauma Informed Care (TIC)

Vision: To advance Trauma-Informed Care in Ohio

Mission: To expand opportunities for Ohioans to receive trauma-informed interventions by enhancing efforts for practitioners, facilities, and agencies to become competent in trauma-informed practices

Ohio's Trauma-Informed Care Initiative

Since Summer of 2013, an interagency workgroup comprised of leaders from Ohio Mental Health and Addiction Services (MHAS) and Ohio Department of Developmental Disabilities (DODD) has been meeting to formulate plans to expand TIC across the state. A portion of the “Strong Families, Safe Communities” funds from the Governor’s Office have been earmarked for this purpose. The National Center for Trauma-Informed Care (NCTIC)/SAMHSA and Ohio Center for Innovative Practices (CIP) have also consulted formally, and Additional conversations and advice from Ohio Hospital Association, OACBHA, Ohio Council, PCSAO, and many others.

What is trauma?

Individual trauma results from an event, series of events, or a set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects on the individual’s functioning and physical, social, emotional, or spiritual well being.

The Three E's of Trauma

Events

The focus on events puts the cause of trauma on the environment, not in a defect of the person. This underlies the basic principle of the trauma-informed approach. Events can be a single event, a series of events, or chronic conditions. People may experience an event directly, witness an event, or feel threatened hearing about an event that affects someone they know.

There is a wide range of events that could potentially create trauma, including violence, abuse, terrorism, forced displacement, natural disaster, or death of a loved one.

Experiences

A person’s experience of trauma may be profoundly affected by when, how, where, and how often it occurs. Trauma can result from a single event or multiple traumatic events over time.

The focus on experience highlights the fact that not every person experiences the same events as traumatic.

Experiences that produce trauma include

bullying and humiliation,
dysfunctional household or living situation,
constant feeling of powerlessness,
and feeling different or not feeling accepted.

Effects

Trauma often has lasting and adverse effects on a person’s functioning, as well as their mental, physical, social, and emotional well-being. Trauma can result in

confusion, sadness, anxiety, agitation, dissociation, and chronic or recurrent physical pain, such as headaches or stomachaches,
difficulty developing healthy attachments and relationships and difficulty identifying, expressing, and managing emotions,
impairment of brain and nervous system development,
impairment of immune system response,
and engagement in risky behaviors, such as smoking, substance abuse, self-harm, unsafe sexual practices, and diet and exercise habits that lead to obesity.

TIC Principles

What is trauma-informed?

A program, organization or system that is trauma-informed

Realizes the widespread prevalence and impact of trauma
Understands potential paths for healing
Recognizes the signs and symptoms of trauma and how trauma affects all people in the organization, including:
- Patients
- Staff
- Others involved with the system
- Responds by fully integrating knowledge about trauma into practices, policies, procedures, and environment

Core Principles

Safety
Trustworthiness and transparency
Peer support and mutual self-help
Collaboration and mutuality
Empowerment, voice, and choice
Consideration of cultural, historical, and gender issues

Outcomes

Improved quality of care and impact of care
Improved safety for patients and staff
Decreased utilization of seclusion and restraint
Fewer no-shows
Improved patient engagement
Improved patient satisfaction
Improved staff satisfaction
Decreased “burnout” and staff turnover

Trauma in Adults: Mental Health

61% of men and 51% of women with a mental health issue reported experiencing at least one trauma in their lifetime with these experiences listed as the most common:

witnessing a trauma,
being involved in a natural disaster,
and experiencing a life-threatening accident.

Trauma in Children

According to a study in 2015 by the National Council for Behavioral Health,

children with histories of traumatic experiences are twice as likely to have chronic health conditions;
children with traumatic experiences are 2.5 times more likely to have repeated a grade in school;
and exposure to violence in the first years of childhood deprives children of as much as 10% of their potential IQ.

In recent years, research, training, and information have helped build awareness about the impact of trauma on the lives of children. This awareness has resulted in a new understanding about the importance of addressing existing trauma exposure and preventing re-traumatization.

The leadership in federal, state, and local child-serving systems, including child welfare, mental health, juvenile justice, education, primary care, Medicaid, and others, has recognized the urgency of changing the fundamental question from “What’s wrong with you?” to “What happened to you?”

The challenge now is to ensure this paradigm shift permeates all levels of child-serving systems and is disseminated to everyone who interacts with the lives of children, from policymakers at the state level to the receptionist in the local provider agency.

Trauma in People with Developmental Disabilities

According to a 2014 study by Envision,

one out of every three children and adults with developmental disabilities will experience abuse in their lifetime,
and more than 90% of the time, abuse is inflicted by a person charged with protecting and supporting them.

Characteristics that influence rates of trauma in the developmental disabilities population:

people with developmental disabilities may have been taught to comply with authority figures and do as they are told without question,
they are dependent on caregivers for a longer period of time,
they are sometimes impaired in their ability to communicate or in their mobility,
people with developmental disabilities who experience cognitive or processing delays may not understand what is happening in abusive or exploitive situations,
and sometimes the signs of abuse are attributed to the person’s disability and ignored.

Shift in Thinking

As trauma symptoms are normalized, feelings of shame and self-blame are reduced or eliminated. Symptoms are viewed as the body’s attempt to re-establish balance to the nervous system.

Instead of “What’s wrong with you?” ask “What happened to you?”
Instead of “What is your diagnosis?” try “What is your story? What brought you here?”
Instead of “What are your symptoms?” ask “How have you coped and adapted?”
Instead of “How can I best help or treat you?” ask “How can we work together to figure out what helps?”
Instead of “Here is what you need to work on ….” ask “How can I support changes in your behavior that will benefit you?”

Shift in Thinking: Coping Mechanisms

Survival Response: Fight

Behavior: Struggling to regain or hold on to power, especially when feeling coerced
Labeled by the system as non-compliant, in denial, combative, challenges authority, or treatment resistant

Survival Response: Flight

Behavior: Giving in to whoever or whatever is in a position of power
Labeled by the system as passive, cannot be helped, or using the system

Survival Response: Freeze

Behavior: Disengaging completely, keeping to oneself, leaving services, abandoning housing
Labeled by the system as chronic or unmotivated

Shift in Thinking: Resiliency

Resiliency is an inner capacity that when nurtured, facilitated, and supported by others empowers children, young people, and families to meet life’s challenges with a sense of self-determination, mastery, hope, and well-being.

Components of Resiliency: The Four C’s

The four C’s of resiliency are control, connection, competency, and contribution.

Control: Young people should be able to make choices and have a sense of control over their surroundings and event outcomes.
Connection: Young people should have caring, supportive network of connections, including family, friends, and those in the community.
Competency: Young people should work on their own weak or lacking skills, such as communication, problem-solving, or social skills.
Contribution: Young people should use new skills and self-control to help the group succeed at challenges and projects; offering opportunities to help others and chores make young people feel like they have value or worth. They need to feel they can contribute in some way.

The Trauma-Informed Approach: The Four R’s

Realize: People at all levels of an organization have a basic realization about trauma and understand how trauma can affect people and their families. They also understand the potential paths to recovery.
Recognize: People in the organization are able to recognize the signs and symptoms of trauma in clients, families, staff, and others involved with the system.
Respond: The program, organization, or system responds by applying the principles of a trauma-informed approach in policies, procedures, and practices.
Resist: A trauma-informed approach seeks to resist re-traumatization.

Putting it All Together

Ask: “What happened to you?”

Then, support resiliency with four statements.

“I believe you.”
“Thank you for trusting me enough to tell me.”
“I am sorry that happened to you.”
“I support you whatever you choose to do.”

Team members can also

show genuine concern and be sensitive to physical or intellectual barriers, gender, and cultural issues.
understand that troubling behaviors that might seem uncomfortable likely helped the person cope and survive under extreme circumstances. Seek to understand their experiences and identify a path to healing.
help link the person with trauma-responsive services and ensure continuity of care between organizations and across systems.
assume that every young person has experienced trauma, even without knowing their personal history.
create a welcoming environment that promotes a feeling of safety and non-violence. Pay attention to physical space, tone of voice, loudness of music or side conversations, and eliminate anything that could be intimidating or anxiety producing.
be aware of personal space. Realize that some painful memories may be triggered by touching, hugging, behaving authoritatively, standing over the person, or blocking their exit.
recognize that certain practices such as seclusion and restraint may create trauma and trigger traumatic memories. Make a commitment to non-violence in words, actions, policy, and practices.
support meaningful power-sharing and decision-making.
use tools and approaches that help calm fear and anxiety as a preventative and healing method rather than engaging in confrontational approaches that focus on coercion or control of external behavior.