 This episode was prerecorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through all CEUs. Register at allceus.com slash counselor toolbox. I'd like to welcome everybody to today's presentation, Trauma-Informed Care, A Sociocultural Perspective. This is actually the second in a series of three, five videos that we're doing on trauma-informed care. The other one on screening and assessment we did about a week and a half ago. So we're going to continue with trauma-informed care. We're going to define what trauma is. Explore why trauma-informed care is important. Learn the three key elements to a trauma-informed approach, realizing, recognizing and responding. Well, identify trauma-informed intervention and treatment principles. Learn how to anticipate the interplay between treatment elements and the client's trauma history. And identify some of the cross-cutting factors of culture. So what you might need to consider when you're providing culturally responsive care. So what is trauma? A lot of times people think of trauma as that strict DSM-5 criteria. And that's just not it. Not everything rises to the level or specifically meets that definition that's set forth in the DSM-5. And we don't want to minimize the impact of traumatic events on people even if they don't meet that criteria. So traumatic events are those that the person experiences a threat of death, serious injury to self or self-concept, or threat to the physical integrity of self or another. So, you know, there's a lot of things that can be considered traumatic. And, you know, think back over your life and things that have happened that have been traumatic. I remember, for example, unfortunately we had a dog who got out and was hit by a car right in front of me. That was traumatic to me. Now, was it something that was going to end up producing PTSD? No. But it was very traumatic to me and, you know, something I had to deal with. There are other traumatic events that can happen. And we're going to talk about a bunch of those. There can be human-made traumas, such as mechanical error that causes a disaster. Think of bridges that have collapsed or buildings that have collapsed because of man-made error. War, terrorism, violence or neglect. So anything a human is responsible for, whether they intended to traumatize people or not, is considered a human-made disaster or human-made trauma. Traumatization can also occur from neglect, which is the absence of essential physical or emotional care soothing and restorative experiences from significant others, particularly in children. So trauma, again, think about a two-year-old who is experiencing child neglect. That is extremely traumatic when they can't get the one person who they rely on for survival to pay attention or when that person abuses them. So traumatization can occur from neglect and abuse and in addition to other things. Trauma can be a product of nature and, you know, that's kind of vague there. And some things kind of cross. Like if you have a house fire, is that human-made because of faulty wiring or is that an act of nature or an act of God? It doesn't really matter. But you want to consider what's going on here. Acts of nature or acts of God generally people aren't looking to place blame somewhere. They're just like, it happened, it really sucks. Flooding, hurricanes and tornadoes. Now, during this period, people are struggling with trying to make sense of things and they may assign blame to a certain extent. The flood happened and, you know, the levees broke. So we're going to blame the people who were responsible for maintaining those. A hurricane came. We didn't get warning ahead of time, far enough ahead of time or we weren't able to batten down the hatches or maybe self-blame. I should have gotten out when I thought it wasn't going to be a big deal. So products of nature are other, is another category of trauma. Trauma can occur at any age or developmental stage and often events that occur outside the expected life stages are perceived as traumatic. So a child dying before a parent, for example, or a teenager who has cancer. A lot of times that's perceived more dramatically, if you will, than maybe, you know, an 80- or 90-year-old who gets cancer. I mean, I remember when my daddy was diagnosed with cancer, he was 47. And that was pretty dog-on traumatic to me. And so it's not just a teen and I don't want us to limit. We want to look at, was it traumatic to the individual? Maybe it wouldn't have been traumatic to you. You know, things that happen to an eight-year-old that are traumatic to them aren't traumatic to me as, you know, significantly older than an eight-year-old. Personal illness can be traumatic. If you have, if you get diagnosed with chronic fatigue syndrome or fibromyalgia or something that is going to be chronic and maybe significantly impact your life, that can be traumatic because all of a sudden the way you thought things were going to be is no more. You know, you're going to have to adjust your life plan. And job loss can be traumatic. So there's a lot of things that can happen sort of out of the natural order that you expected things or they change your vision for how the future or how life is supposed to be. And that's traumatic. It upsets the apple cart and you've got to figure out, okay, how do I make sense of all this? Because this isn't how I had the story written. Individuals may experience the traumatic event directly, witness the event, feel threatened or hear about an event that affects someone they know. So people don't have to necessarily directly experience the event. There were a lot of children, for example, during after 9-11, after Hurricane Katrina. I'm sure after Hurricane Harvey and some of the others that I haven't been directly involved in. When the media repeatedly plays this and parents are just glued to the TV and they're watching this disaster and the replay 24-7 for, you know, weeks on end, children don't have a good concept of that happened once and they're just replaying it. Children's experience is continuing to happen and it can be very traumatic and threatening and they stop feeling safe. So again, it would be traumatizing to a child to see that on the media. For adults, it can be somewhat traumatic too because it's a constant reminder that this can happen. You may not be safe anywhere. So just because you weren't there doesn't mean it's not traumatic to you. And it's not just the event itself that determines whether something is traumatic but the individual's experience of the event. Are they equipped to handle it? One of the screening things that we use in determining people who've gone through critical incidents, first responders who've gone through critical incidents, whether they might be at higher risk for developing PTSD. See how I hedged there because we still can't predict with any certainty. We look at prior mental health and substance abuse issues. You know, could this trigger a relapse? We look at prior stressors in the past six months. Were they already drained of all of their, you know, resources? You know, have they been dealing with thing after thing after thing? And there's actually a name for that. It's called cascading trauma, but I digress. How similar were they to the victim? I mean, if they were the victim, obviously that's going to be really impactful. If they were similar to the victim, law enforcement officers that respond to a child that accidentally shoots themselves and dies. If they have a child of a similar age at home, then, or, you know, who's recently been that age, then it could put them at higher risk. If the trauma happens in a safe zone, we all have safe zones and I've shared in other classes, I was at the University of Florida when Danny Rawling was going through butchering students. And, you know, before that happened, I would go jogging at 10 o'clock at night and not think anything of it. I'd have my headphones on, blaring, completely oblivious because I felt safe on campus. And all of a sudden, campus was not safe anymore. You didn't feel safe in your dorms or safe in your apartments. So if it happens in an area that you perceive as a safe zone, then it could be potentially more traumatic. So those are all, oh, and social support. It's really important after a trauma for people to receive social support within the first four hours. After that, people start compartmentalizing and kind of pushing stuff down. Within the first 24 hours, that's another sort of mark point where people are starting to really compartmentalize and try to figure out what to do with it and the shocks wearing off. So you really want to make sure that people get access to healthy social support within the first four hours, ideally, but definitely the first 24 hours. And that will significantly reduce the chances that they're going to develop PTSD. Now, everybody may or anybody may develop acute stress disorder in response to a trauma. But what we want to do is prevent it from being an ongoing issue. Just because something doesn't meet DSM-5 criteria for acute stress disorder or PTSD doesn't mean it wasn't traumatic. Trauma is something that overwhelms our coping capacity. It happens and we're like, oh, I didn't see that one coming. I feel like I got hit in the gut and I have no idea how to deal with this. I remember watching the second airplane going into the Twin Towers just sitting there in shock and disbelief going, what am I supposed to do with this information? And it affects the whole self. It's not just a cognitive thing or an emotional thing. It affects people physically, emotionally, intellectually and cognitively, spiritually and interpersonally. So aside from surviving a violent crime or physical or sexual abuse, those are the things we typically think of when we think of trauma. What other things are traumatic to people? The loss of a spouse or a child, especially if it's unexpected. You know, when my grandmother's husband passed away, it wasn't as traumatic. Combat, accidents. The National Child Traumatic Stress Network identifies community violence as traumatic. You know, those random shootings that somebody had mentioned. Complex trauma, which is, you know, when something happens over a prolonged period of time or there are multiple experiences of it. Domestic violence and bullying, early childhood trauma, medical trauma. If something was extraordinarily painful, children who go through, if they get burned, and they've got to go through the burn ward and have skin grafts, that is extraordinarily traumatizing. Children who are going through cancer treatment, that can be extremely traumatizing. Natural disasters, neglect, physical abuse, refugee trauma. And not just because of where they came from, not just because of what they saw in their home of origin, but being displaced, having to come here, having to find or go wherever, having to find a new place to be and a new place to seek safety, and being separated from their culture can be extremely traumatic. School violence, sexual abuse, terrorism, and traumatic grief. And traumatic grief is generally happens when there's a loss outside of the natural order, like a child dying too soon. And that can happen if you have an eight-year-old at home and you have a baby and the baby dies of sits and, you know, the child is going, oh my gosh, how did this happen? What happens? So there are a lot of different issues and you can read up on it if you want to later. And then how does the trauma affect the whole self? Physically, you know, trauma causes brain changes and we're going to talk about that maybe later today. I think it's tomorrow. It causes actual changes in cortisol levels in the brain. It can change responsiveness of the HPA axis and what I call the threat response system. It can cause problems with sleeping because if the body is on high alert, people are not going to get quality sleep. And it can cause a range of stress related and physiological complications. Emotionally, trauma can make people feel depressed, helpless, hopeless, anxious, angry, grief-stricken, guilt-ridden. There's a whole bunch of emotions that can happen with trauma. And when you feel this way, that compounds the physiological problems, headaches, stress, inability to sleep, nightmares. Intellectually and cognitively, it changes the way people think. Instead of viewing this world as a safe, predictable place, all of a sudden it's kind of chaotic and unsafe. Spiritually, that sense of connection with others, a lot of people who've been traumatized start to feel detached and disconnected. And interpersonally, you know, people who've been traumatized may either fear other people, not trust other people, or not feel like anyone else understands. So they may start withdrawing from their social supports. And somebody did bring up in here, you know, back to the other question. Motor vehicle accidents can also be very traumatic. Our neighbor was in a motor vehicle accident and she broke her spine. And she was in the hospital for like eight months, had to learn how to walk again. She still experiences chronic pain. I worked with an officer who responded to a crash on the interstate. And, you know, that was very traumatic because of the events that ensued. And so he was traumatized from that. So there are a lot of things we need to consider when we're thinking about traumas and just defining for yourself, what does trauma mean? So why is trauma-informed care important? Well, because a lot of people have been traumatized. And when we look at the average population, 61% of men and 51% of women report experiencing one trauma in their lifetime. And when I say average, that means just Joe on the street. When we start looking at people who are actually presenting for counseling for depression, substance abuse, anxiety, yada, yada, that number shoots way up. The National Epidemiologic Survey on Alcohol and Related Conditions indicates that 71.6% of the sample reported experiencing trauma. And in a survey at the Elacica County Jail, which I was able to take part in when I worked down there, 99% of the female inmates reported having experienced trauma. So we were looking, we were trying to identify co-occurring issues and what might be prompting recidivism and stuff, but we did find that rather startling statistic. For those of you who haven't been in my class before, I'm not going to test you on these numbers, but I want you to see the magnitude of the problem, which should drive home the point that whether you work in a jail, a correctional facility with probationers, or in a mental health sort of facility, the chances that you're working with somebody who's experienced at least one trauma is pretty daggone good. So trauma-informed care becomes even more important. The Adverse Childhood Experiences Survey tried to highlight why it's important for us to understand the impact of trauma, and obviously they were looking at childhood trauma. But their research has shown that an Adverse Childhood Experience leads to disrupted neurodevelopment, you know, the stress, not sleeping, high levels of anxiety leading to the adaptations in the limbic system, disrupt neurodevelopment. There's social, emotional, and cognitive impairment, because a lot of times kids have difficulty figuring out how to deal with this stuff. There's an adoption of health risk behaviors, smoking, drinking, overeating, disease, disability, and social problems, and early death. And they found that the greater the number of Adverse Childhood Experiences, the greater the likelihood that someone is going to climb this pyramid. Trauma-informed care improves screening, assessment, and treatment planning. It helps us look at, you know, what is motivating this symptom? You know, what is causing this depression or this anxiety? You know, you say somebody's depressed, so, you know, maybe they need more serotonin. So give them to the doctor, and the doctor prescribes SSRIs. The SSRIs aren't doing any good, or aren't doing a lot of good. So you look and you say, what might be causing that serotonin imbalance? And we know that when the HPA axis, the threat response system, is activated, serotonin levels decrease because we want somebody. We don't want people to be relaxed. We want them to be on high alert. So being under constant stress reduces levels of serotonin. So if somebody's got treatment-resistant depression, we may want to look at what might be causing that serotonin imbalance. Could it be trauma? Could it be something else going on down here that needs to be addressed so the person is not on high alert all the time? TIC decreases the risk for retraumatization. Even if we don't deal with the trauma directly, which I hope is never the case, but even if that weren't to happen, if we don't retraumatize the person, at least we're not compounding the problem. It enhances communication between the client and treatment provider, decreasing risks associated with misunderstanding the client's reactions and presenting problems or underestimating the need for appropriate referrals. Why is this person drinking? Why is this person having difficulty sleeping? Why is this person agitated? A lot of the symptoms of PTSD and even sub-threshold PTSD look like anxiety symptoms. So is it anxiety or is it a trauma-related reaction? And if it's a trauma-related reaction, how do we help the person deal with it in addition to or instead of cognitive behavioral, for example? TIC improves cost-effectiveness because services are more appropriately matched to clients from the outset. We start helping them see the connection between their trauma, their reactions, their current emotional state, and we get them to the right services ahead of time and they start feeling like, oh, I'm not completely broken, this is treatable. It ensures the implementation of decisions that will optimize therapeutic outcomes and minimize adverse effects on the client and ultimately the organization. We want to have good treatment outcomes. We don't want our treatment response rates to be really low. We don't want to have grievances filed against us because therapists aren't getting it, aren't responding in a way that's appropriate or maybe re-traumatizing someone. Clients and staff are more apt to be empowered, invested, and satisfied if they're all involved in the ongoing development and delivery of services. Not only clients, but also staff are more likely to be empowered and think about it. When you're working with a client who starts doing really well, who starts seeing improvements, part of you in the back of your head says, I'm doing something good. I'm making a difference and our sense of self-efficacy increases. In addition to the client who's going, I'm doing good. I'm making some progress. Trauma-informed care increases clinicians' self-awareness of trauma triggers. It's likely that many of us have experienced trauma ourselves. So what triggers our trauma responses and what are our trauma responses? You may not even realize some of the stuff you do might be trauma-related. So it helps you understand and draw connections in your own behaviors and also to be aware of what might trigger you so you can use appropriate self-care not to get burnt out, etc. It increases clinician-awareness of the variety of emotional, behavioral, interpersonal, and physical symptoms of trauma because a lot of times we don't think about, could this be because of trauma? We just think this person's intermittent anger outbursts, are intermittent explosive disorder or whatever. Instead of thinking maybe this is the person's reaction out of fear feeling like they've been back in a traumatic situation. To provide appropriate responses to trauma-related reactions or symptoms. So when somebody is in a group setting, maybe they're in a therapy group and it starts getting tense and they get up and they walk out or they start yelling or changing the subject which is not an appropriate response on any front. Instead of thinking that they're being resistant, if a trauma-informed care or trauma-informed clinician will say, might this be making the person feel triggered and unsafe? And if so, how can we respond to it? It prevents the clinician from delving too deeply, too quickly and unwittingly harming the client. You don't ever want to, in that first session, go tell me all the details of what happened in your trauma. Number one, that's just rude. I mean you don't want them to bear their soul the second they meet you and there's no safety there yet. But number two, sometimes they want to and it's up to us as we talked about in screening and assessment to slow them down and let them know that in order for them to be safe, you want them to be able to effectively process it, you want to make sure that they have the coping skills to be able to handle the traumatic memories and you want to help them develop that. So you're going to work on the trauma and you're going to talk about it but let's not put the cart before the horse and get them in a situation where they feel scared and out of control. It aids the client in developing a safety net to prevent further trauma because they start to understand what triggers their trauma and the connection between triggers and their reactions and how to deal with them. So now they start developing basically a relapse prevention plan. It provides clinicians with trauma specific resources and referrals and enables them regardless of setting to provide quality care regarding trauma related issues which may be contributing to other presenting problems or trigger a relapse of mood or substance abuse disorders. So there are a lot of reasons that trauma informed care is important and helpful. Three key elements of trauma informed care, realizing the prevalence of the trauma, recognizing how trauma affects all individuals involved with the program, organization or system including its own workforce and responding by putting this knowledge into practice. And one of you mentioned on the last slide and I kind of saved it for this, that when we hear traumatic experiences, when we hear people's stories, it can be traumatic. There used to be a philosophy or theory or whatever you want to call it of dealing with critical incident stress where people would sit in a group and they would all share their perception, tell their story of what they saw or what they experienced and the research has found that, not surprising, that ends up potentially traumatizing other people in the group. Now, is it still done? Yes, it is. But it is important to recognize that trauma is often not something that you want to delve into details deeply in a group because it can re-traumatize or traumatize people even if they haven't had a similar experience. By hearing it, they're just like, oh my gosh, I can't fathom what that would be like. But it affects us. It affects us on an emotional, cognitive, interpersonal, spiritual level when we hear these stories of what's happened to people. In terms of the organization, if your organization is there and providing good trauma-informed care, you're increasing your presence in the community, you're increasing your reputation as a good place to go when you've got trauma, and you're a resource within the community system, you become a resource for people who've been traumatized, so we've got somewhere to send people. And we can say that this organization, this agency, really can help you with your trauma. Trauma-informed care begins with the first contact the person has with the agency. That's when they call in for their first appointment. If somebody is rude, dismissive, abrasive, it can be very off-putting. It requires all staff members, from receptionists to clinical staff, administrators, and even board members, to recognize that the individual's experience of trauma can greatly influence his or her receptivity to an engagement with services, interactions with staff and clients, and responsiveness to program guidelines, practices, and interventions. Board members and an administration comes in when we're trying to sell them the importance of trauma-informed care. If we have a trauma-informed system, then we will be able to better engage clients, improve their interactions, and improve their responsiveness to treatment. And generally, when administrators hear that, they're like, make it so. Trauma-informed care includes program policies, procedures, and practices to protect the vulnerabilities of those who've experienced trauma and those who provide trauma-related services. And vulnerabilities, you know, that's pretty wide. When you're exposed to this trauma, whether it's from hearing about it or from experiencing it, you know, how did it make you feel? How did it make you feel vulnerable? How did it make you feel unsafe? How did it change the way you perceive the world? And the system, your program, has to be responsive to that, so you're not recreating. Promoting trauma awareness and understanding recognizes that the prevalence of trauma and its possible role in individuals' emotional, behavioral, cognitive, spiritual, and physical development, their current presentation, and their well-being. So we recognize that trauma can be really pervasive. Think about people who are diagnosed with borderline personality disorder, for example. A lot of people with BPD, diagnoses, when you look back over their history, what do you see? You see a history of trauma. Neglect, trauma, those sorts of things. So the person never developed a stable sense of self, never felt safe. There are a lot of things going on with that individual. And so it's important to recognize that trauma can affect a person in many, many different ways for many, many years, and we need to recognize that. Another principle of trauma-informed care is to recognize that trauma-related symptoms and behaviors originate from adapting to traumatic experiences. It's an adaptation. It's not a pathology. When somebody adapts to a trauma, they're trying to survive. They're trying to protect themselves. If we look at it that way, instead of a pathological response, such as hyperarousal or hypervigilance or night terrors, how can that be an adaptation? How can that be a survival mechanism? But these behaviors influence how individuals respond to the environment, relationships, interventions, and treatment services. We need to understand where it's coming from and help them see that it's protective. Once they can see that, then they can say, okay, what's a better way I can protect myself? Trauma-related symptoms shape people's assumptions about their world, how they view others, their sense of safety, their future. Are they hopeful or do they not see themselves making it through the year? And how they see themselves. Do they feel resilient? Do they feel like survivors? Or do they feel incompetent at regulating emotions, at surviving, and feel bad about themselves and pretty much defeated? And when we get down to different symptoms of trauma, you'll pretty much realize that every symptom can be a symptom of trauma. But yes, cutting can be a symptom of trauma because that's the one thing the person has control over, is that pain. And the endorphins that are released during the cutting can numb some of the emotional pain. So look at what function is the cutting serving? Is it getting people's attention? Is it numbing pain? Is it producing endorphins? Is it providing the person with a sense of control? Trauma-related symptoms can include agitation, irritability, and hostility. So how are those protective? Well, if you've been traumatized, when traumas happen, you're not generally not expecting them. So if you stay more alert, agitated even, if you stay more on guard, more protective, then you're less likely to be caught unawares. If you're more agitated, you know, you're kind of like that little chihuahua that, you know, he's like, come on, come on, bring it here. I got it. But the agitation serves as a protective mechanism. It prepares you for bad things to happen. It's like expecting that other shoe to drop. And hostility can push other people away and give you a sense of power and control when in the past you've lost your power and control. So that makes sense. The question is, is that how you want to be? Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world? Well, if you saw the world one way through these beautiful rose-colored glasses and all of a sudden the bottom fell out, you wouldn't want to be caught unawares like that again. So having these negative beliefs, you know, maybe I was just deluding myself and this is the way it is and life is horrible and people are untrustworthy and yada-yada-yada. Well, that protects you from being disappointed or surprised as much again. And you see a theme here? Hypervigilance, being kind of, being scanning constantly for things that are going on. Scanning when you hear a noise, you're like, what is that? You perk up and you're more aware of everything. It's exhausting to be hypervigilant because it's, you've constantly got stimuli coming in that other people are filtering out. But it protects you from being surprised. It keeps you on guard. Hyperarousal is kind of related and that's when people are easily startled. If there's a loud noise, a backfire, somebody dropped something in the kitchen, whatever the case may be, you startle. A lot of times that happens when there was a noise that preceded whatever the trauma was. Self-destructive behavior and this can be driving fast, drinking, thinking, using drugs, smoking, overeating, cutting. Anything that could potentially harm your health can be a trauma related symptom. It can be a way to try to deal with whatever's going on by getting control, increasing happy chemicals, dopamine, serotonin, GABA, endorphins. And it can also be a way of distracting yourself if you're thinking about what you're eating. If you're medicated with nicotine, you may not be thinking as much about what's going on. And yes, adrenal fatigue is also called hypocortisolism and trauma can cause hypocortisolism. So yes, there is a direct link between that. Now does everybody who experiences trauma develop hypocortisolism? No. But it is worth being aware that it can cause adrenal fatigue. Social isolation is another symptom, either because you don't trust people or because you can't handle other people or because you think nobody's going to understand and you don't want them to feel like they have to be supportive of you because you don't think they should have to or you don't think they could handle what's going on with you. There are a lot of reasons people withdraw. We want to look at that. And feelings of detachment or estrangement from others kind of goes along with that social isolation. So we want to look at this. What's causing? Is it a trauma history? Is it, you know, a chemical imbalance? Is what's going on that might be causing it? People may avoid reminders of the event. No joke, you know, when the worst day of your life you probably don't want to be reminded of it. People have flashbacks. Well, flashbacks are kind of your mind's way of going, yeah, remember this? You know, something triggers a flashback and your brain goes, this happened. Now how are you going to protect yourself? Don't put yourself in that situation again. Fear, severe anxiety or mistrust, seemingly obvious, if you've been traumatized or you've been hurt, you know, you don't want to go through that again. Remember, fight or flight, anger or fear, they're kind of both responses to a threat. Depression, loss of interest or pleasure and activities and guilt. After people are traumatized, sometimes that sense of hopelessness and helplessness and being completely out of control can be overwhelming and pervasive. Some people, because they're traumatized, because they're irritable and hypervigilant so much, become exhausted and the depression starts to set in because at a certain point, if you keep trying to change something but nothing changes, your body says, wave the white flag, I give up. I'm not devoting any more energy to that anymore. Sleep problems, emotional numbness, difficulty concentrating and chronic pain. Did you know that serotonin is responsible in part for our perception of pain? So if your serotonin is low, your pain perception is going to be higher or your tolerance for pain is going to be lower, however you want to look at it. Between 15 and 35% of people with chronic pain also have PTSD, according to the U.S. Department of Veterans Affairs. And we've learned through the research that people who have been traumatized in general tend to have a high, even without PTSD, tend to have a higher rate of chronic pain. It could be because of whatever happened in the trauma, if it's a car accident or a burn or whatever. But for some people, there is no physiological damage, so to speak, done in the trauma, but they still have chronic pain, gastric pain, migraines, headaches, somaticizing certain symptoms. We want to view the trauma in context of the individual's environment. Many factors contribute to a person's response. Was it an individual group or community-based trauma? And we're going to talk about that more later in the week. But the resources people have available to them differ greatly depending on, you know, the type of trauma. What are their individual attributes? How old are they? You know, an 8-year-old's going to respond differently than a 26-year-old. Are they similar to the victim? What coping resources do they have? What is their history of mental illness? Developmental factors, including protective factors. What's going on? Are they cognitively able to understand what's going on? How old are they? Do they have social supports? What's their life history? Have they had a pretty good life and they've got some resources and some skills? Or has it been tough going all the way? And they are just, they're without the resources to deal with it. The type of trauma, specific characteristics of it and the amount and length of trauma exposure. You know, a minor trauma that occurs once is going to have a different impact than traumas that occur repeatedly. Law enforcement officers, the intensity of the trauma that they experience may not be huge. Sometimes it is. But they see people on the worst day of their life pretty much every day. And they see things that no one person would really ever want to see. So it's a cumulative sort of thing for those people. So length or frequency of exposure to the trauma adds up and can have a greater impact than maybe being exposed to it one time. What is the cultural meaning of the traumatic events? If the culture perceives the trauma as, you know, negative against the family or as shameful, then it's going to affect the person differently than if the culture goes, we're behind you. This wasn't your fault. You know, this is definitely something you can recover from. The number of losses associated with the trauma. When somebody, you know, if their house burns down, that can be traumatic. So what did they lose? They lost a sense of safety. They were asleep. All of a sudden the house was on fire. Oh my gosh. They lost their possessions. They may have to move to a different neighborhood, change schools. You know, there's a lot of losses there. So you want to look at the number of losses associated with the trauma. Available resources including supports, family supports, community supports, stick with the fire. You know, did the Red Cross come in and help people get, you know, clothing and roof over their head and stuff. And what internal resources do they have, such as coping skills? And what were the community reactions to the event? Was the community supportive? Did they rally around and say, we're going to help you? Did they have vigils? Were they dismissive of whatever happened? You know, whatever. That isn't a big deal. The person just needs to get over it. Or did they blame the person? If so and so wouldn't have, then, you know, so is there an element of that? And when you look at the community, you want to look kind of broadly. So when something happens to a student at school, they have the community at large, but they also have the school community. So how are each one of those, or each of those communities responding to the person? We want to minimize the risk of retraumatization or replicating prior dynamics. So thinking about it, what practices might retraumatize a rape survivor? And we're going to stick with mental health counseling here. We're not going to go into medical practice because there's a lot of things there that can be retraumatizing, too. But rape survivors have lost their power. Rape survivors, if they're put in a group, for example, a coeducational group, they may feel retraumatized. If they have a therapist of the same gender as the person who assaulted them, they may feel retraumatized because they're being asked to be vulnerable to someone. If someone was in a serious car accident, seeing a car accident obviously can replicate the dynamics where one of the places I used to work, we used to take the clients out on excursions and getting into the van and having to trust somebody else to drive you when they're safely could be definitely triggering. Being in the van and getting stuck in a traffic jam and smelling exhaust fumes can be triggering if they were stuck in a, maybe stuck in a car after the car accident. If someone was molested by a pastor or a priest, you know, thinking about if somebody comes in and sits down and your office is just covered in scripture quotations and things, that could be traumatizing. If someone was a survivor of a home invasion, they may not want to have their back to the door. Now we want to be between the client and the door, but we also don't want to have our back to the door. So they may be conscious about not having their back to any windows or doors, or if there is a window, make sure the blinds are closed so the person doesn't feel exposed. What things in your agency takes away power or puts providers in a dominant position? I mean, we can control treatment, we can admit, we can discharge. A lot of times, well-meaning providers tend to take a lot of control over therapy. And or, and this is one of the ones that really irritates me, providers will create a treatment plan for a client and just hand it to them instead of mutually developing the treatment plan. So it takes the power away from the client and says, here, you do this. Well, if they were abused before, if they were told you do this, if they had their power taken away, that can re-traumatize them. Thinking about things in your agency that contribute to a lack of safety. When I worked in residential, we used to have to do fire alarms periodically. Now think about it, if you've got somebody who's survived a house fire, you know, when that fire alarm goes off, you're probably triggering them. Now legally, you have to do fire alarms. So figuring out how to help that client so they're not re-traumatized if they're there when you do a fire drill. What things in your agency may make the client feel misunderstood or dismissed? So just thinking about things that may make the client feel like they're not being taken seriously or that people don't have time to deal with this trauma issue or people don't believe them. Because a lot of times trauma survivors, especially child trauma survivors, weren't believed. So we want to make sure that clients don't feel dismissed. Create a safe environment physically. Privacy, safety from others. Safety from restraint. If clients are afraid that if they get upset, they're going to be put in restraints, they're not going to respond as well. Or they're going to be chemically restrained, as I call it, you know, a good ol' shot of howl doll or something. They may also fear having their kids taken away. If they start telling you about a trauma they experienced that you might say, well, you're unfit to be a parent and I'm going to report you to DCF. So we need to be open about what constitutes a mandatory report and, you know, what doesn't and what you can talk about and what's safe. Emotionally, we want to prepare clients for attending group sessions where another client may express anger, even if it's appropriately. So clients who've been, who've survived abuse, when that starts to happen, it may trigger them. So how can they deal with it? How can they handle it? And what's the appropriate response? And you want to discuss methods for deescalating traumatic stress reactions instead of telling the client not to talk about it. Sometimes people will start having a stress reaction to something and they'll want to talk about how it relates to their prior trauma and they get shut down. They're like, well, that's, we're not talking about that in group right now. Why don't you hold that and we can talk about it after group or something. And that makes them feel dismissed and out of control. So there are a lot of things we can do to prepare and help clients create a safe environment. Identify recovery from trauma as a primary goal. This can happen. This bridges the gap between their mental health, any substance issues, and the traumatic experience. And we say, we can't just treat this depression without addressing this trauma. But, you know, the trauma is contributing to the depression. So we have to treat them both concurrently. It's not either or. We want to support control, choice, and autonomy. Not every client who's experienced trauma and is engaged in services wants, sees the need for, trauma-informed, or trauma-specific treatment. We want to appreciate client's perception of their presenting problems and view their responses to the impact of trauma as adaptive. So if clients say, you know, this happened to me, but it was no big deal, it's not affecting me right now. I certainly don't want to sit there and try to convince them, well, yeah, it is. It is a big deal. Now, in the back of my mind, I might be thinking that, but I'm supporting their control over what we're going to address right now. I may educate them over time about how, you know, the symptom might be a trauma response. But I don't want to continually go after that particular issue of trauma. If the client isn't ready to deal with it yet. Create collaborative relationships and participation opportunities. When I say collaborative, there's us and the client, but there's also collaboration with other treatment providers, provider networks, and the community. In Gainesville, we used to have a week where we would have a lot of different activities for survivors of trauma to be empowered. Excuse me. And, you know, some of it, we would have a survivors quilt that would be on display in the downtown. We would have networks out there to provide information about trauma, to educate about how unfortunately common some of these things are. And involve the community. So the community understands what's going on. And it's empowering and liberating a lot of times for clients to get out there, not only and say, oh, I'm not the only one, but also to say, everybody, there is something that can be done. I want you to start doing something and mobilizing the community. And, you know, somebody asks, is recovery from a situational trauma like fire, natural disaster more possible than recovery from a trauma like childhood abuse or neglect. And to that I would say, recovery from trauma depends on the person more so than the trauma itself. Now, we want to look at the intensity of the trauma. If the person was in the house fire and they got burned over 30% of their body, there's going to be a whole lot more losses involved and it's going to be harder to deal with. So going back here, many, many, many. I can't find it right now, but things that may make the trauma, factors contributing to the person's response to trauma, their life history, developmental factors when it happened, you know, adults will respond differently than children, the cultural meaning of events. We want to take all this stuff into consideration when we're looking at and creating our prognosis, if you will. We want to communicate throughout that recovery from trauma, regardless of what it was and how long and how bad, it's possible. And that's one of the things we want to make sure that people believe and we need to believe that it is possible. Is it easy? No. Is it possible? Yeah. And what they've survived already and done to survive until now has been at least as hard as recovering from the trauma. So they can do this. As far as collaboration, we also want to ensure client and consumer representation and participation in behavioral health program development planning and evaluation. So we want to bring people in from the community, that's one way to get culturally responsive services, but we also want to have those other stakeholders providing feedback about what types of traumas they see, the impact it has and what are their suggestions for what we can do. Do we need to go into the schools? Do we need to have handouts available at pharmacies? Do we need to have a special section in the library that people can quietly or not quietly, but discreetly access resources if they don't want to ask for help yet. Familiarize the client with trauma informed services. And this starts by reducing them to program services in a manner that expects them to be unfamiliar with these processes. Even if they've been in treatment before, start out and act like they've never been into treatment. Explain to them what we're going to do, why we're going to do it, why it's important. So they feel like they're involved in the process and they feel like they can put the brakes on at any time and go, yeah, I'm not sure I really want to go there. But it's a value and type of trauma related questions that may be asked during the intake process and whenever I get to that section on child abuse and stuff, before I go into it, for us, it used to be at the beginning and it drove me crazy, so I put it towards the end of my assessment. But I would stop and I would say, okay, I need to ask you these questions and I explain to them why it's helpful for me to understand if they've had a trauma history that they don't have to answer if they don't feel comfortable and they don't need to go into detail. They can simply answer yes or no, but if they want to elaborate a little, that's fine. And then we go on from there. It's also important that they understand who's going to be able to see this because they may not want to talk about being raped when they were aid or by their stepfather or whatever if they think that somebody might use it in court or, you know, whatever the case may be. Educate clients about trauma and normalize traumatic stress reactions. Help them understand their symptoms in terms of an adaptive way or a way of adapting to a trauma, to being out of control, to being hurt, a way of adapting in order to survive. And discuss trauma specific interventions and other available services such as trauma focused, cognitive behavioral, EMDR, hypnosis, acupressure or acupuncture. There are a lot of different techniques that can be used in addition to standard cognitive therapy. Incorporate universal routine screenings for trauma because so many people have been touched by trauma you should just assume that there's a likelihood that people will have been exposed to trauma. So ask everybody about it and view trauma through a sociocultural lens. Use a strengths focus perspective to promote resilience. So when you're talking with them, when you're doing the assessment, talk about their coping skills and their stress management techniques. What works for them? What social supports do they have? What are their positive characteristics and strengths and accomplishments? So let's look at this person, not just at a trauma, not just at a disorder or a symptom. But okay, you've got this other stuff going on here, which is unfortunate and devastating. Let's look at this other stuff about you that's helped you survive until now. Let's look at your resources. Foster trauma resistance skills. Remembering that clients are the expert on their own lives and have learned to adapt to survive. Emphasize the concept of commitment, control and challenge. Be committed to the things that are important in your life. Focus on the things that you have control over and view mistakes, obstacles, tragedies, whatever as challenges. How can you use your skills to conquer these or to deal with these? Demonstrate organizational and administrative commitment to it by having policies and procedures that emphasize trauma informed procedure. Develop strategies of secondary trauma in clinicians and other people on staff and promote self- care. We want to make sure that clinicians are separating work and home life and they're not taking it home with them and they're taking good care of themselves. And finally, remember to always provide hope that recovery is possible. To better anticipate the interplay between various treatment elements and the more idiosyncratic aspects of particular client's trauma, you can work with the client to learn the cues he or she associates with past trauma. So slamming doors, for example, triggers one of my clients who watched his best friend commit suicide with a gun. So that loud noise, I know that's a trigger. So we want to start identifying what triggers these symptoms. Obtain a good history. Now this is not going into deep detail about their trauma. It's just a good history of their life. Maintain a supportive, empathetic and collaborative relationship. Encourage ongoing dialogue and provide a clear message of availability and accessibility throughout treatment. Because we don't know exactly what parts of treatment might trigger or what topics you might talk about might trigger their trauma. So it's important to keep that door open and keep a dialogue going. If we trigger something, we're over here talking about cognitive reframing. And then they start feeling triggered. They start feeling anxious about something. We may not necessarily make the connection between the two, but it's important for the client to be able to say, I'm feeling triggered right now. Let's talk about it, because we didn't expect this discussion over here to trigger it. But it happens sometimes. Three main beliefs of social ecological approach. Environmental factors greatly influence emotional, physical and social well-being. If you live in a chaotic, dangerous, loud, scary environment, yeah, you're going to function emotionally physically and socially differently than if you're in a supportive, safe environment. A fundamental determinant of health versus illness is the degree of fit between the individual's biological, behavioral and sociocultural needs and the resources available to them. If you've got somebody who's habitually emotionally dysregulating and they're in an environment that dismisses that and says you're overreacting, you know, you need to get a grip and they're constantly feeling dismissed, then their mental health is going to take a toll, which is kind of one of the basis of or basis of dialectical behavior therapy. So we need to make sure that people's needs are getting met. And prevention, intervention and treatment approaches integrate a combination of strategies targeting individual, interpersonal and community systems. So yes, we're going to work with the individual who's been consistently bullied in the school. But we're going to also work with the school where maybe you're going to try to get into the health class and teach some interpersonal effectiveness skills. And we're going to get into the school and to the community and raise awareness about bullying and what parents can potentially do. Some populations and cultures are more likely than others to experience a traumatic event or a specific type of trauma. So we need to be aware of this. Cultural influences, cultural influences not only whether certain events are perceived as traumatic, but also how an individual interprets and assigns meaning to the trauma. Some cultures say it was an act of God. It's a punishment. It's this. Other cultures don't believe that and they say it was an unfortunate thing that happened. So how does the culture perceive it and look upon it? Some traumas may have greater impact on a given culture because those traumas represent something of significance for that culture or disrupt cultural practices or ways of life. So does it disrupt their culture in some way? Culture determines acceptable responses to trauma and shapes the expression of distress. So some cultures will somaticize a lot of their distress. Other cultures have more emotional, emotive reactions. Culture significantly influences how people convey traumatic stress through behavior, emotions and thinking following the trauma. So it changes. Culture will kind of tell them how they should think now. Trauma symptoms vary according to the type of trauma and the culture. Sexual abuse may be addressed differently in a culture than robbery. Culture affects what qualifies as a legitimate health concern which warrants help. So if the culture says no, we deal with in the church or this is something we deal with in the family, then the person may never seek therapy. In addition to shaping beliefs about acceptable forms of help seeking behavior and healing practices, cultures can also provide a source of strength, unique coping strategies and specific resources that aren't available to other cultures. It may be a strong religious community or extended family network, etc. So culture can be very adaptive and helping. We want to view relationships through a culturally sensitive trauma-informed lens by understanding our role as a provider within the family's world. We want to gain a better understanding of the roles and dynamics within the family so we know kind of where they at in supporting our identified patient. And we want to consider and facilitate the inclusion of others including extended family, clergy, and healers when treating patients. So we want to ask clients, who do you want as part of your treatment team? We want to view assessment through a culturally sensitive trauma-informed lens, remembering that the manifestation and expression of symptoms differ depending on personal, familial, and cultural beliefs and practices. When we're working with families and individuals, we want to try to use their own terms, not our own jargon. And trust in and comfort with the provider has been shown to be associated with increases in patient disclosure in some cultural groups. And finally, view treatment through a culturally sensitive trauma-informed lens, remembering that healing comes in many different forms. People's ideas, beliefs, and values may differ from yours and they may even differ from their families. So we want to ask them what does healing mean to you? If you recover from, or when, not if, when you recover from this trauma, what does healing look like? What does recovery look like? Be sure that you've integrated the family's understanding of diagnosis, prognosis, and healing into your treatment planning. So use the terms as much as you can as they do and use the definitions for recovery as much as you can. And consider each family's resources and barriers to help seeking and utilization of supportive services within the community. If there are supportive services, great. Make sure it's something the family is willing to interface with. Or, you know, if there aren't resources, how can you develop those resources? Not all people are comfortable going and seeking food stamp assistance, for example. Not all people are comfortable getting assistance from the Red Cross or whatever. So even if services are there, they may, culturally, it may not be appropriate, or the person may not feel okay accessing those services. So we may need to look at alternate resources. Trauma-informed care requires clinicians to look at the individual and their adaptive responses, the family and social supports and their response to the trauma. The organizations and individuals involved with the person and their responsiveness, you know, are the organizations and individuals that are supposed to be providing support and care being responsive. The community and its responsiveness or reaction to the issue. The individual's culture and its conceptualization and prescribed reactions to the trauma. Trauma-informed care requires clinicians to conduct universal screenings, because we figure that most people have exposed to trauma. Explore traumatic symptoms as adaptive responses. Maintain a high level of personal awareness and self-care so we don't get burnt out or suffer the effects of secondary victimization. And work with the client, family and community to develop a partnership for treatment. Are there any questions? Alrighty everybody, I really appreciate you being here today and we will pick up tomorrow with part three of this series. If you enjoy this podcast, please like and subscribe either in your podcast player or on YouTube. You can attend and participate in our live webinars with Dr. Snipes by subscribing at allceuse.com slash counselor toolbox. 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