Trauma-Informed Care

Trauma-Informed Care
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After completion of this course on Trauma-Informed Care you will receive 6 Contact Hours/Continuing Education Units
Is this course for me? This course is for RNs, LVNs, Psych Techs, and anyone else interested in the topic of Trauma-Informed Care

Course Synopsis:

This course will explore the topic of emotional and psychological trauma and how to provide caring, compassionate, and empathetic services that are trauma-informed. Trauma doesn’t discriminate; it affects people of every race, age, ethnicity, and socioeconomic level. Trauma can be a single isolated event or a series of events, and a traumatic experience involves some type of a threat to one’s physical or emotional well-being and can bring out feelings of terror, helplessness, and lack of control and power.

Traumatic experiences can impact and alter an individual’s perception of themselves, their world, and the people around them and can disrupt the victim’s biological, cognitive, and emotional functioning as well as their identity, relationships, and social interactions. As service providers, it is imperative that we implement care and services that follow the tenets and principles of Trauma-Informed Care (TIC).

In this course, you will learn about several principles and tenets of TIC. You will be challenged and inspired to provide the best care possible to those who have been affected by the ravages of traumatic experiences.

Course Objectives:

Upon completion of this course you will:

  • Be able to define trauma
  • Recognize various types of trauma
  • Understand trauma’s impact on mental and physical health
  • Understand the Adverse Child Experiences (ACE) Study
  • Describe and understand principles & tenets of Trauma-Informed Care
  • Recognize the importance of responding to trauma disclosures appropriately
  • Understand the importance of managing vicarious trauma and compassion fatigue
  • Recognize trauma’s impact on society

About Your Instructor:

Donn Kropp founded ClickPlayCEU out of a desire to bring others to greater levels of health and wellness. With over ten years of experience in a variety of healthcare and human services settings, Donn brings a seasoned, yet fresh approach to continuing education. Donn holds a BSN from the University of North Carolina, Charlotte and a Masters in Healthcare Leadership from the University of California, Davis.

Course Approvals

This course is approved by the following governing boards & organizations:

  • CA Board of Registered Nursing: CA Provider # CEP 15849
  • District of Columbia Board of Nursing: CE Provider #50-14108
  • California Board of Vocational Nursing Provider # V10810
  • Psychiatric Technicians Provider # V10806

Transcript

Trauma-Informed Care
1. INTRODUCTION
Hi, my name is Donn Kropp. Welcome to our course on Trauma and providing trauma-informed care. When I refer to trauma I’m not talking about physical trauma like your finger getting smashed or breaking a femur. This course is on emotional and psychological trauma. A traumatic experience involves some type of a threat to one’s physical or emotional well-being and can bring out feelings of terror, helplessness and lack of control and power. Traumatic experiences can impact and alter an individual’s perception of themselves, their world and the people around them. Trauma can disrupt the victims biological, cognitive, emotional functioning as well as their identity, relationships and social interactions. Trauma affects every race, age, ethnicity, and socioeconomic level. Nobody is immune from trauma. Trauma can be a single isolated event or a series of events. Trauma can impact every area and aspect of a person’s life. Get this, research is showing that there’s a relationship between traumatic events and impaired neurodevelopment, and immune systems responses and subsequent heath risk behaviors resulting in chronic physical or behavioral health disorders. The sad and tragic truth is trauma steals something from its victim. It may steal innocence, power, feelings of safety, happiness, personal peace, health, wellness and can take years off of your life. Here’s the good news and where you come in. You can help restore what’s been stolen. That’s right, with appropriate assessments, screenings, support and intervention people can overcome traumatic experiences. That’s good news, right?

Trauma is actually kinda difficult to understand. It can’t be viewed narrowly but must be understood broadly taking into account biological, psychological, interpersonal, community and societal factors. Understanding trauma and a person’s response to it we must consider the contexts in which it occurred. Traumatic experiences complicate a person’s capacity to make sense of their lives and to create meaningful consistent relationships in their families and communities. Relationships are so dang important. We are hard wired to be in relationship with others that are caring and loving. I’ll come right out and say that this course may be difficult for some. We deal with some sensitive issues and topics. We hope you’ll listen closely though because understanding trauma and providing appropriate services is so very important. Before you think this course isn’t for you just give me a few more seconds of your time. Most people only think that dealing with emotional or psychological trauma is for the mental health or social services field. We don’t think that’s the case at all. We feel that this topic applies to everybody in the healthcare and human services field because the statistics on those who have experienced trauma is so high.
The prevalent nature of trauma means that there is a good chance that a person you are caring for, your neighbor, friends, family member or even yourself have experienced or is currently suffering from some type of trauma at some level. Trauma used to be thought of as an abnormal or uncommon experience. But listen to these staggering statistics related to trauma. A report of child abuse is made every ten seconds in the United States [Display with these references- (Childhelp, 2013)] Children who experience child abuse and neglect are 59% more likely to be arrested as a juvenile, 28% more likely to be arrested as an adult, and 30% more likely to commit violent crime. [Display stats with these references-(Child Welfare Information Gateway, 2006)] Trauma histories are pervasive among youth in America, especially youth from diverse cultural backgrounds. [Display stats with these references-(Marcenich, 2009)] The Center for Disease Control and Prevention state more than 1 in 3 women, 35.6%, and more than 1 in 4 men, 28.5%, in the United States have experienced rape, physical violence, and/or stalking by an intimate partner. [Display stats with these references-(CDC, 2013)] Boy, those are some pretty sobering and alarming statistics.
Now, the statistics just mentioned relate to serious forms of trauma that can have a lasting impact. These numbers are disturbing but what makes it more concerning is that rape and physical violence, are only a few of the many types of trauma that can occur.

You’ll see later on in this course that there are several forms of trauma and they too can have long and enduring effects. You’ll find out in a little bit that trauma isn’t necessarily a big huge cataclysmic event, it can be as seemingly small and minute as not being soothed as a young child. This expansion on the understanding and definition of trauma means the numbers of those who are affected by traumatic experiences is much higher than we once thought. This then means we must be better prepared to understand and serve those who are traumatized in a sensitive and caring manner. Being trauma-informed is what this course is about. You may have heard the terms trauma sensitive or trauma aware. The concept of trauma-informed care is relatively new but it’s coming to the forefront of healthcare due to the fact that so many people suffer from trauma and we are now finding out that trauma and its destructive nature can harm an individual not only psychologically and emotionally but also physically. We are just now making the connection between trauma and health problems. Expensive and health problems such as cancer, depression, diabetes and heart disease.
Since the beginning of time man has experienced trauma. Watching your dad fight a saber tooth tiger or being mulled by a wooly mammoth were probably common occurrences back in the day. Also wars, violence and destruction have been the norm throughout history. It seems like we as human beings have been doing bad stuff to each other since the beginning of man. The world has seen its share of wars, brutalizing one another, murder and enslavement. The list of traumatic events throughout human history is endless. Though we’ve always known that these events can be harmful, at least psychologically, we are just now finding out at molecular levels that trauma can actually change our DNA, affect our brains and our long-term health. We are also learning and understanding that trauma shouldn’t be narrowly defined to only include devastating and catastrophic events but it must also include a host of events such as neglect, having a family member imprisoned and divorce. All these findings make understanding Trauma and trauma informed care all the more important. It’s time to start practicing the universal precautions approach to patient care which means we presume that all of the people and patients we serve have a history of some type of traumatic event and we change and amend our practices accordingly.

The goal of this course is to introduce you to trauma and trauma-informed care. We want to raise awareness to help direct either ourselves or the people we serve toward a path of discovery for recovery. In this course we want you to see people in a whole new light and to be more observant and compassionate when you interact with a patient or even a co-worker in your place of work. Hopefully this class helps you to become aware of your own traumatic experiences so you can recover and heal. We want you to get to the root of your difficult traumatic experiences. I’ve also been a witness of and victim to trauma and getting to the core and understanding the root issues has helped me be the awesome person I am today. Also in this course we want you to see society and humanity in a whole new way. When you see a homeless person begging on the street or a drugged out individual we want you to keep in mind that their destructive choices and lifestyle are more than likely the result of traumatic experiences. Drugs, alcohol, and other risky behaviors are probably coping mechanisms to deal with the pain, agony and sorrow.

It’s important to note that many of us out there working in our respective facilities and organizations are practicing many of the principles and tenets of Trauma-informed care, and that’s great. The problem is you’ve been practicing these certain skills but there hasn’t been a name for what you’ve been doing. The development of the term Trauma-informed care gives this approach a name, a common language, and a better understanding of how to practice it.
The development and production of this course was a life-changing process for me. I hope it will be the same for you. Thanks so much for joining me. If you’re ready, let’s go ahead and begin.

2. OBJECTIVES
In this course we’ll cover many topics surrounding trauma. By the end you’ll understand a number of key definitions and concepts. Emotional and psychological trauma isn’t as cut and dry as we once thought. There are several different types of trauma and we’ll explore each one. Also, in this course we’ll look at trauma’s impact on mental health as well as physical health. We’ll look at a groundbreaking research study called the Adverse Childhood Experience or ACE study that examined the role of childhood trauma on physical and mental health in adult life. The results of this study will blow you away and is a game-changer to the healthcare and human services field.
Finally, in this course we’ll look at the concept of trauma-informed care and introduce you to its principles and tenets so that you can develop the skills necessary to create environments that are positive and therapeutic. Also, we’d like for you at the end of this course to leave with a broader perspective on the role trauma plays. This topic isn’t just for mental health or social services but it needs to be talked about in every sector of the healthcare world, in your communities, at your lunch and dinner tables. It’s imperative that we all raise awareness so that we can move our society toward better health, wholeness and wellness. Well, are you ready to get started? If so, let’s begin.

3. WHAT IS TRAUMA
What do you think of when you hear the word trauma? Probably you think about some type of cataclysmic event like a war, terrorism, murder, earthquake, or some other event of mass destruction. You’re right, trauma is all of those things and people who have experienced these types of events either, as a victim or witness can be traumatized for life. This course isn’t about Post Traumatic Stress Disorder-PTSD, but we must touch on it to a little bit to set the context for trauma. Frequently in the news we hear about War veterans suffering from PTSD. The diagnosis of Post traumatic stress came about in the late 1970s when thousands of Vietnam Veterans came back to the states with significant psychiatric illness related to the war. Victims of war certainly deal with experiences that are beyond the understanding of most of us who have not been in combat or exposed to such atrocities.
Our thoughts and understanding about trauma often times start and stop with PTSD. But in this course you’ll see that many people who have been traumatized can suffer from symptoms that aren’t necessarily captured in a PTSD diagnosis. What do I mean by that? To be diagnosed with Post Traumatic Stress disorder you must meet certain criteria and suffer from certain symptoms outlined by the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association. Currently to be diagnosed with PTSD you must have been exposed to an event that involved or held the threat of death, violence or serious injury. Exposure could have happened in a few ways such as you: Experiencing the traumatic event personally, You witnessed the traumatic event in person, you learned someone close to you experienced or was threatened by a traumatic event or you are repeatedly exposed to graphic details of traumatic events like you are a first responder to an accident scene. Along with witnessing the traumatic events one or more of the following signs and symptoms occur that cause significant distress and interfere with the ability to perform normal daily activities and tasks lasting longer than one month.
Symptoms include:
Reliving the experiences of the traumatic event, such as having distressing images and memories. Having upsetting dreams about the traumatic event. Experiencing flashbacks as if you were experiencing the trauma again. Experiencing ongoing or severe emotional distress or physical symptoms if something reminds you of the traumatic event. PTSD in children manifests differently. Signs and symptoms for children younger than six may include: Reenacting the traumatic event or aspects of the event through play or the child may experience Frightening dreams that may or may not include aspects of the traumatic event. The reason I wanted to highlight the PTSD diagnosis is because this course aims to expand our understanding of trauma and look at segments of our population who are still traumatized and have life-long issues due to trauma but their experience and symptoms of trauma don’t specifically meet the criteria of PTSD. If we only think of people and their circumstances of trauma as fitting into the confines of a PTSD diagnosis we’ll perhaps be tempted to dismiss someone’s experience of trauma and not provide the proper care or resources they need. It’s important for us to really understand that a huge portion of the population have experienced trauma and they need just as much care and attention as someone who meets a PTSD diagnosis.
The conversation we want to get started here in this course and what we want you to spread all over the planet is that trauma comes in different forms and each type can have long-lasting impact on brain development and function in both children and adults and affect overall health later in life. Trauma is probably our nation’s single most important public health challenge. A lot of our efforts in the healthcare and human services realm has been placed on managing symptoms. Understanding and addressing the root causes of trauma is what this course is all about and may be the key to significantly helping those who have been traumatized and improving the health of our society.
So then, what exactly is trauma? As you’ll see later on in this course is that there are several definitions of trauma. But really trauma can be described as any event that overwhelms a person’s capacity to cope and has long-lasting impact.
There are many different types of situations and events that are traumatic. Years of work in the field of trauma experts has generated a lot of definitions of Trauma. The American Psychological Association or APA narrowly defines trauma as exposure to actual or threatened death, serious injury or sexual violence. Some have criticized the APAs limiting definition and suggest that events may still be traumatic even if one’s own, or someone else’s, physical integrity isn’t threatened. The Substance Abuse and Mental Health Services Administration broadens the definition and has come up with the 3 E’s definition which states individual trauma results from an EVENT, a series of events or 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. Other definitions of trauma state that traumatic events can refer to an experience that overwhelms a person’s resources for coping and this experience disrupts a persons sense of safety, perception of control and the ability to self regulate. Self-regulation refers to a person’s capacity to control impulses both to stop doing something if needed or start doing something if needed. So, an example of disrupted self-regulation would be a case where a child who has experienced trauma may not have the self-regulatory mechanisms to pay attention in class or a patient that may not be able to control angry outbursts. If we don’t understand the nature of trauma and its effects on individuals we’ll default to labeling people as difficult, oppositional, rebellious, unmotivated, antisocial or worse. How many times have you been driving down the road and seen a homeless person and your first thought was, “Why don’t they just get a job. They’re so lazy”. We do that all the time, but statistically speaking that person was probably a victim of trauma and has lacked the means, resources, social support and tools to overcome their traumatic experiences. So, be very careful not to judge or put labels on people.

Trauma can be broadly categorized into 4 main groups: Acute, Chronic, Complex and Historical or intergenerational trauma. Acute trauma is caused by a single traumatic event that causes extreme emotional or physical stress. Examples include: an accident, an act of violence, a natural disaster, having a loved one pass away, or an instance of physical or sexual assault. I experienced acute trauma a few years back. I was doing relief work in Haiti after the massive earthquake that devastated the capitol city of Port-Au-Prince and killed thousands of Haitians. After returning from the trip when I was near a wall or brick building I was afraid it would come crashing down on me. I had this fear because so many died in the earthquake from faulty cinderblock walls falling. Over the course of a few weeks this fear subsided and it doesn’t affect me now. Experiencing a traumatic event, even if its just one time can be terrifying and cause thoughts of fear, helplessness, terror and be so overwhelming that it leads to other physical and mental health illnesses.
Chronic Trauma on the other hand is an experience of multiple traumatic events over a long period of time. An example of this would be those who live in war torn areas who experience death, destruction and the constant threat of violence over and over day-in and day out. A few years back I traveled to Kashmir India after a devastating earthquake. Now this area has been in dispute between Pakistan and India since 1947. There have been 3 wars fought and there continues to be skirmishes to this day. President Clinton during his presidency stated that this was the most dangerous place on earth. Tens of thousands of lives have been lost in this war and the people who live in this area are subjected to long-term, chronic trauma with no end in sight.

A third category of trauma is called complex. Complex trauma is a specific kind of chronic trauma that includes multiple traumatic events that are repetitive, prolonged and cumulative and involves direct harm, exploitation and maltreatment of some kind including neglect and abandonment by primary caregivers or responsible adults. Complex trauma often occurs at developmentally vulnerable times of a victim’s life especially in early childhood or adolescence but can occur later in life as well. The absence of essential physical or emotional care in the form of soothing experiences is traumatic to children. Kids need our hugs, kisses and affection. They need to be encouraged and feel safe.
The fourth category of trauma is perhaps something you haven’t heard about before and is often overlooked. I know when I first heard about it I was blown away. This category is called Historical or intergenerational Trauma. Historical Trauma is defined as multigenerational trauma experienced by a specific cultural group. That means trauma that was experienced in past is having an effect in the present day. The trauma is being passed on from grandparent to parent to child. Collective cultural trauma has been experienced by a number of social and ethnic groups such as the Jewish experience of the Holocaust, African Americans and slavery, and Native Americans victimized, killed and nearly extinguished from this continent by settlers from Europe. The trauma perpetuated against the Native American population was plentiful and included; violence, rape, murder and removal from their land. What compounds the trauma with Native Americans is that there was a suppression and forced assimilation that led to loss of language, ceremonies, spirituality and their culture at large. In this present day Native American adults are at greater risk of experiencing feelings of psychological distress and more likely to have poorer overall physical and mental health and unmet medical and psychological needs. Suicide rates for Native American adults and youth are higher than the national average, with suicide being the second leading cause of death for Native Americans from 10-34 years of age.

We’ve just broken down the 4 categories of trauma. Do you remember what they were? If not here they are again- Acute trauma- which is a one time occurrence
Chronic Trauma is the experience of multiple traumatic events, often over a long period of time. Complex Trauma is a specific kind of chronic trauma that includes multiple traumatic events that begin at a very young age, typically less than five years and are caused by adults who should have been caring for or protecting the child. Historical or intergenerational trauma is the emotional and psychological pain over a lifespan and across generations as a result of massive group trauma.
Let’s know talk a little bit about the specific types of trauma that can occur: such as neglect, psychological abuse, physical and sexual abuse, community violence, combat-related violence, accidents, disaster and Adverse Childhood Experiences. I mentioned the Adverse Childhood Experiences study before in the objectives. We’ll highlight it here first but get into more deeply later on. The ACE study was conducted to see the effects of adverse childhood traumatic experiences on long-term health. The researchers conducted a study by using a questionnaire. The questionnaire asked ten questions- Five were questions about experiences of trauma related to physical abuse, verbal abuse, sexual abuse, physical neglect and emotional neglect. The remaining five questions were related to other family members: and asked if a parent was an alcoholic, if a mother was a victim of domestic violence, if a family member was in jail, if a family member diagnosed with a mental illness, and if the child experienced the disappearance of a parent through divorce, death or abandonment.
The ACE study did a lot but one of the things it did was open up a new realm of understanding about what trauma is. I had a mentally ill family member in my household growing up. I didn’t realize until developing this course that this is a form of trauma that could have long-term implications on my mental and physical health. The ACE study as you’ll find out is a game changer and should change the way we deal with those who are victims of trauma.

There are wide and varied reactions to trauma. Generally speaking interpersonal trauma or trauma that has occurred due to the purposeful deliberate actions of another tends to cause more severe reactions in the victim then does the result of a random event such as a natural disaster for example a hurricane or tsunami.
During or after traumatic events occur there can be different types of symptoms such as alterations in a victims state of consciousness. Amnesia, hypermnesia which is remembering more and more details as time goes on. A traumatic experience can lead to dissociation which means the victim emotionally detaches themselves from the negative experience. Depersonalization and derealization can occur too during and after a traumatic event. This is a feeling that you’re outside of your body and observing yourself or there is a sense that the world around you isn’t real and that you are in a dream like state.
People also experience flashbacks and nightmares of the particular event. Children who are traumatized can start having problems at school, they may have difficulty paying attention, become numb, listless and “checkout”. Orientation with time and space can become an issue as the traumatic event disrupts their sensory and motor functions. Trauma can cause a child to become out of touch with their feelings and they may have no idea what they are feeling or have any language or words to describe what is happening on the inside.
It’s important to note that the experience of trauma isn’t the same for everyone. A similar horrible event maybe experienced as trauma for one person and not another. Traumatic events are typically determined by the meaning someone assigns to the event and how much that experience disrupts them physically or psychologically. If there was betrayal or humiliation involved that increases the likelihood that a person will experience it as a traumatic event. Another factor that increases the likelihood that someone may assign trauma to an event or experiences is if there is silencing. Silencing means that the victim was told by someone else not to share about the event or the victim themselves never shared about the event because of shame and/or humiliation.

An example of a traumatic event because of betrayal could be a boyfriend and girlfriend breaking up. Now, typically this wouldn’t be thought of as traumatic per say unless the one who is broken up with is humiliated or betrayed. Let’s say for example you have two girls Susie and Jill. They are best friends and Susie is dating Bob. Susie is totally in love with Bob but one day she finds out that Jill and Bob have been secretly dating. Everyone knows this but Susie, and she is heart-broken, ashamed and betrayed by two people, her best friend and boyfriend. This type of scenario happens all the time but Susie is extremely sensitive and she thought she would eventually marry Bob. Susie’s humiliation was compounded by the fact everyone at school knew about Jill and Bob and also they spread rumors and divulged the most intimate details of Susie and Bob’s former relationship. Susie never shares here feelings about the humiliation and shame she experienced with anyone. She starts feeling anxious to go to school and starts feeling anxious and depressed. Now break ups are pretty common but due to the fact that Susie silenced herself, there was an enormous amount of embarrassment, shame and humiliation and she didn’t have any social supports to help her. This situation is traumatic to Susie and she goes on to experience a lifetime of anxiety, depression, suspicion, pain, and humiliation. As you can see traumatic experiences don’t have to be out-of-the-normal cataclysmic events.

Another example of an experience that may not typically be seen as traumatic but could have life-long ramifications because of humiliation is the case of Joe and Tim. Joe and Tim are two freshman college student boys that entered a fraternity. Typically fraternities have some kind of initiation rites. Joe has been told by his dad growing up about fraternity Alpha, Kappa, Pi, Delta, Chi. and he has been a part of this fraternity for generations. The dad has told him about all the initiation rites and silly things that can happen. Then we have Tim. Tim is the first one in his family to ever go to college and joins the fraternity just to make some friends and doesn’t really know about all the rituals and silliness that happens. On initiation night the two boys are subjected to humiliation and ridicule by being made to sing songs in their underwear while getting eggs thrown at them. Joe is eating this up and loving it but Tim is humiliated, ashamed and embarrassed. Joe and Tim went through the exact same experience but Tim is having nightmares, flashbacks and starts becoming socially anxious. The way we handle circumstances and traumatic experiences depends on a lot of factors such as the way we were raised, developmental stage, personality, temperament, cultural beliefs, religious beliefs, social support, resiliency and many other factors. Joe’s family supported the fraternity experience and thought it was great. Joe had his father cheering him on and a long history of social support. Where as Tim didn’t really have any prepping or support from family because he was the first one in his family to go to college. With Tim this situation disrupts him emotionally, socially and physiologically. He can’t get the images of being hazed out of his mind and he starts to withdraw and lose his appetite. Eventually he drops out of school. Here too you can see that there was a situation we wouldn’t typically equate as traumatic but the events disrupted Tim and his capacity to cope and it impacted him in such as way he eventually dropped out of school.

We’ve talked about the events and experiences of trauma so far so what about the effects? The effects of trauma can occur immediately or over time, sometimes years down the line. People may not even recognize that the connection between the effects and the event. A person may begin feeling and suffering from a range symptoms such as the inability to cope with the normal stresses and strains of daily living. An individual may also become unable to trust and benefit from relationships. For the trauma victim it may become more and more difficult to manage emotions, memory, attention, thinking and behavior. Overtime the effects of trauma can start to manifest as changes in the brain and body and start effecting overall health and well-being.
As you’ve learned in this segment the term trauma has historically been prescribed to only events and experiences that are extraordinary, cataclysmic or catastrophic in nature such as war, natural disasters, physical and sexual abuse. However, experiences such as loss of power, household dysfunction and neglect are being recognized as common and pervasive and been found to have lifelong adverse effects upon the victim. The experience of trauma is not as cut and dry as we once thought. A seemingly small event could be traumatic to one and not another. An event that is traumatic has certain characteristics such as their is disruption in the victim physically and psychologically. There is also a sense of humiliation, betrayal, or silencing that shapes how the event was experienced. Other factors such as the victims cultural beliefs, availability of social supports and the developmental stage of the individual have bearing on whether someone views and experience as traumatic or non-traumatic.
This newfound understanding of trauma is super important because it challenges traditionally held beliefs and assumptions that trauma and its effects should be handled solely by mental and social work services. We believe that the ramifications and issues that trauma brings is a threat to public health and we must all take steps to address and understand.
In our next section we’ll take a look at the biology of trauma.

4. THE BIOLOGY OF TRAUMA
Trauma affects our brain’s. Let’s take a few moments and talk a little bit about brain development, stress and trauma. It’s critically important to have a basic understanding of the development of the brain so that we can understand the impact of stress and trauma.
The brain is an amazing organ and its development and the connections it makes is mind-boggling…pun intended. Early experiences of childhood have a significant effect on the development of the brain infrastructure. This brain infrastructure provides the foundation for all future learning, behavior and health. The brain infrastructure could be compared to building a house. If you build on a weak or faulty foundation the strength and quality of the house is compromised and could eventually fall down.
Our brains are built overtime and through an ongoing process. Just like it takes a while to plan, build and furnish a home- our brains work much the same way. The brain’s construction begins before birth and this process of building continues on into adulthood. Brain cells, called neurons, are constantly making connections and pathways. Simple neural connections form first which are then followed by very complex circuits and skills. In the first few years of life there are seven hundred to a thousand new neural connections forming not every year, not every day, not even every hour…seven hundred to a thousand connections are forming every second. Wow! That’s a lot. The brain can’t keep this pace up for too long of making all these connections so after a little while the connections between the cells are reduced through a process called pruning. Like you prune a branch of a tree the brain does the same thing. Pruning is important for the brain because it gets rid of connections rarely used so it can strengthen the other connections and become more efficient. Isn’t the brain amazing!
The infrastructure of the brain is comprised of billions of connections between neurons in different parts of the brain. These connections enable lightening fast communication between cells that specialize in performing different types of brain functions. The early developmental years are the most active time in a human’s life where connections between neurons are made. The cool thing is we continue to create neural connections all throughout our lives and the pruning process occurs continually as well getting rid of connections infrequently used. The old saying, “use it or lose it” holds true here. It’s never too late to change our brains and create healthy and positive brain connections but building a strong and positive brain infrastructure early on can set us up for health and well-being later in life.

In the first few years of life your brain is developing circuits and connections at a fast pace and has the most plasticity. Plasticity means the brain’s ability and capacity to change. In the early years of life this is where the brain has the greatest opportunity or vulnerability. Developing and establishing a strong brain infrastructure for life is a lot easier early on at a young age. Again, if we use the analogy of the house…is it easier, cheaper and less of a hassle to repair a home that was built on a faulty foundation or to ensure the foundation was sturdy and strong to begin with before we built? Obviously it’s difficult make repairs after a home has already been constructed on a bad foundation. I do want to interject here that we as humans always have the capacity to change and develop new brain circuits so we should never think of ourselves as powerless and unable to change. We as humans have the amazing ability to adapt, change and overcome. The human spirit and brain has the capacity to overcome all types of adversity. That’s the great part.
Our genetics and the experiences that we go through shape our brains.

A major ingredient in this brain’s developmental process is the serve and return interaction between children and their parents and other caregivers in the family or community. The serve and return interaction is one of the most important elements in shaping the development of the brain. The serve and return interaction is when a young child reaches out for interaction through babbling, gestures, facial expressions or crying. The return portion is the adults response back to the child through the same kind of vocalizing or gesture back to the child, a hug or some other form of affection. This back and forth activity is critically important in developing the wiring of a child’s brain and is typically a natural occurrence. The baby cries or coos and the parents will respond often times without thought. We do it all the time right. Cutchy..cutchy coo and all those silly baby noises we make. When there’s not a response back from the parent or caregiver or if the response is inappropriate, such as responding back in anger, the infrastructure of the brain doesn’t build and form like it is meant to. If this building process doesn’t happen correctly or is stunted because of trauma and other toxic stressors there can be delays in learning and behavioral difficulties for the child.
Throughout life our minds, bodies, emotions and our social interactions are intertwined. The brain is a highly specialized organ with multiple functions that operate in coordination with other parts of the body. The emotional and social well-being of our surroundings are critically important in ensuring our brains function appropriately and effectively with all aspects of our body. If the environment around us is filled with stress, trauma, neglect and other stressors the infrastructure of the brain and its development is impacted. When an environment is charged with violence, neglect and other forms of trauma a child will experience something called toxic stress. Toxic stress describes the disruption in brain architecture and other developing organ systems that occur when a child is exposed to strong, frequent or prolonged adversity.
Toxic stress can also cause a cascade of events such as weakened immune system, disruption in the hormone systems of the body and even the way DNA is read and transcribed. These disruptions in of the body’s systems can lead to disparities in language skills, attention, social skills and physical health all which can affect success in school, the workplace and society. It is important to note here that supportive and responsive relationships with caring adults as early in life as possible can prevent or reverse the damaging effects of toxic stress.

We all have stress. Stress can come from a lot of different sources like not being able to pay your mortgage, your boss is being a jerk and hard to deal with or you have to get your continuing education done and you are forced to watch a course online…wait a minute, this isn’t causing you stress is it? I hope not.. if it is pause me right now and go get a nice cup of chamomile tea take a deep breath and we’ll be waiting for you after you get mellowed out and refreshed. For the rest of you let’s talk about stress and our body’s a little bit. Generally, our body’s have the amazing ability to adapt and cope with the stresses of life. There are certain mechanisms that have been built into our bodies that are triggered automatically when we encounter stress and harm.
Experiences of trauma cause stress and disrupt our homeostasis. Remember that word, homeostasis? It just means that our body’s physiologically are in stable state of equilibrium. Homeostasis is where we want to be. Unfortunately different circumstances throw off our body’s balance and disrupts our state of homeostasis. Stress in general triggers our body’s fight, flight, freeze or submit mechanisms. If you don’t know what this is we’ll cover it in a bit. Short-term stress isn’t bad, it actually is helpful in getting out of potentially danger situations, but the long-term effects of chronic stress from trauma have been attributed to higher rates of cardiovascular disease, diabetes, cancer and gastrointestinal disorders. In this section of our course we want to understand the mechanisms, bodily systems, chemicals and so forth associated with the stress response.
Let’s go over a little bit of anatomy and physiology.
Stress or stimuli that cause us fear affects the functioning of the sympathetic nervous system and endocrine system of our bodies.
The nervous system consists of the brain, spinal cord, sensory organs and all the nerves that connect these organs to the rest of the body. The Nervous System is responsible for the control of the body and communication to all its many parts. The brain and spinal cord are part of the central nervous system and is the control center for the body. This system acts as the control center of the body by providing its processing, memory, and regulation systems. The central nervous system takes in all of the conscious and subconscious sensory information from the body’s sensory receptors to stay aware of the body’s internal and external conditions. Using this sensory information, it makes decisions about both conscious and subconscious actions to take to maintain the body’s homeostasis and ensure survival. The central nervous system is also responsible for the higher functions of the nervous system such as language, creativity, expression, emotions, and personality.
The peripheral nervous system includes all of the parts of the nervous system outside of the brain and spinal cord. These parts include all of the cranial and spinal nerves, and sensory receptors. The somatic nervous system is a division of the peripheral nervous system that is responsible for stimulating skeletal muscles in the body. When I want to move my arm and I move it then that is my somatic nervous system doing its job.

The autonomic nervous system, which is a division of the peripheral nervous system, is often called the automatic nervous system because it controls involuntary or unconscious muscle control like that of the heart and glands. There are 2 divisions of the autonomic nervous system in the body: the sympathetic and parasympathetic divisions.
The sympathetic division controls the body’s “fight, flight, Freeze, Submit ” response to stress, danger, excitement, exercise, emotions, and embarrassment and increases respiration and heart rate, releases adrenaline and other stress hormones, and decreases digestion to cope with these situations. The parasympathetic division forms the body’s “rest and digest” response when the body is relaxed, resting, or feeding. The parasympathetic works to undo the work of the sympathetic division after a stressful situation. Among other functions, the parasympathetic division works to decrease respiration and heart rate, increase digestion, and permit the elimination of wastes.
When there is some type of stimuli that causes us fear or stress a mechanism known as the Amygdala and Hypothalamic-Pituitary-Adrenal Axis gets triggered. Dang, that’s a mouthful. When our body’s experience stress the body’s defensive mechanisms kick in. This defensive action system mobilizes are entire body by flooding us with powerful chemicals to help us survive. When we are threatened this fight, flight, freeze or submit mechanism sharpens our senses our eyes dilate, our hearing improves, smells sharpen we become hyper vigilant and our brains filters and screens out only the most relevant information to survive. The chemicals released give us more access to oxygen and glucose to fuel our body’s to survive. Endorphins are released that help with decreasing pain that can be disabling. A ton of stuff happens in our bodies during a threat. This response is called hyper-arousal and on an unconscious level our minds and bodies choose a survival-based action of either: fight, flight, freeze or submit. People respond differently in a hyper-arousal state. Some get very stimulated and hysteric and others may just look stunned and become very mellow, laid back, quiet and withdrawn. Most reactions to life’s stressful events fall somewhere between the extremes of fight and submit.
Let’s get a little deeper into our body’s anatomy and physiology and break down further our response mechanisms by organ systems. Specifically, the body and particularly our brain have several mechanisms that help us deal with stressful events. Let’s talk about the Amygdala first. The word amygdala comes from the Latin word for Almond. You can see how it got its name, it looks like a almond and is roughly the same size. You have two amygdalae. Our amygdalae are super important and essential in our ability to feel emotions such as fear. This organ has a lot of jobs and is complex and it functions to control fear responses, secretes hormones and is responsible for the formation and storage of emotional memories.
If a saber tooth tiger is behind you during a walk your amygdala is stimulated and your heart starts to pound and all kinds of hormonal activity is occurs. The amygdala is kind of like an alarm system. It lets us react almost instantaneously to the presence of danger. The amygdala gets its information from your senses like eyes, ears, nose and all of that information goes to the amygdala. Whenever it gets triggered it sends the alarm signals to your prefrontal cortex. The prefrontal cortex is in charge confirming or canceling the alarm. So, when you are on your walk you hear something that sounds of a saber tooth tiger. The sound could mean danger but it might not be. Your amygdala is firing off alarms to your prefrontal cortex you turn around and notice it is just a little kitty cat and your prefrontal cortex cancels the alarm and all is well.
The amygdala also forms and stores memories that have been associated with emotional events. It also responds and calls up other areas of the brain to pay attention and makes the rest of the brain better at learning and can help us to pay attention to our surroundings. Now, when the amygdala is repeatedly engaged and continuously activated this can lead to hyper-vigilance or being always aware and can lead to anxiety, exaggerated startle responses, irritability and anger outbursts. Imagine a child who is constantly seeing violence. After an original traumatic event occurs any procured threat that reminds the body of the original trauma, like a sound, smell, facial expression will activate the amygdala to alert the body and stimulate the release of hormones in other parts of the body.

When a particularly stressful or traumatic even occurs the brain sends a message to two cone shaped glands that sit on top of our kidneys like ice cream on a cone. These are called adrenal glands and secrete two powerful and potent hormones called epinephrine and norepinephrine. These two chemicals are typically known as adrenaline and noradrenaline, respectively. These guys increase the amount of glucose or sugar in the blood stream and increases our heart rate and blood pressure. Under stress the brain also tells the pituitary gland, the little peanut-sized gland that sits at the base of your brain, to stimulate the adrenal glands to release cortisol. Cortisol is a hormone with a number of functions but one thing it does is it keeps our blood sugar high in order fuel the body, again, to be able to fight off some type of danger or run like crazy. Cortisol makes stored glucose immediately available to our organs. It’s like all of a sudden having a full tank of gas poured into your tank. These awesome mechanisms that occur in our body without thought are really great when you are up against a short-term stressful event like being attacked by a saber-toothed tiger. This system, however, isn’t supposed to be on-going and long-term. Over time the very same systems that protect you can start to harm you. When constantly in an hyper-arousal mode the chemicals and organ systems can increase the likelihood of developing numerous health problems such as: anxiety, depression, digestive problems, blood sugar imbalances, heart disease, sleep disturbances, weight gain, memory and concentration problems and other chronic illnesses.
An environment and life that’s filled with constant stress and trauma can affect the long-term health of an individual. On a typical day or weak you may experience a few moments of hyper-arousal, something at work or your drive home will pump up your blood pressure and cortisol is pumped into your body. After our brains have canceled out the danger we should go back to a state of homeostasis. The effects of an environment when the stress doesn’t go away is toxic and can have life-long implications on health and well-being. Children are particularly vulnerable. When caring for individuals in our respective facilities and organizations we must be aware of the hyper-arousal state and initiate care and services that minimize the bodies arousal and alarm mechanisms. Doing your part to decrease anxiety and stressful stimuli can go a long way in helping an individual who has experienced trauma and is living in a constant state of hyper-arousal. Next, we’ll talk about some of the signs and symptoms displayed by someone who has experienced trauma.

5. EXPERIENCES AND RESPONSES TO TRAUMA
One of the most important and significant ways to be Trauma-informed is to have an understanding of the signs and symptoms of trauma as well as an understanding of the reactions and responses to trauma by a victim. There is no one size fits all everyone reacts differently and has their own timeline of when and how they will react to some type of trauma experience. In this section we’re going to explore some of the more common signs and symptoms a victim may encounter immediately following or long after a traumatic event.
Again, some people might respond and react very classically and have textbook responses to trauma. Others may display signs and symptoms that are very subtle and barely noticeable. The way an individual reacts to trauma depends on a lot of different variables. We highlighted them earlier but we’ll mention them again. Factors such as temperament, individual characteristics along with developmental stage and the meaning an individual assigns to trauma as well as sociocultural factors all affect responses to that trauma.
[Illustrate Domains and Use Slide to show reactions in time with narration]
Let’s now go over a few common reactions to trauma. I want to break the reactions up into five different domains of Emotional, Physical, Cognitive, Behavioral and Existential or Spiritual Reactions. I also want to break each of the domains up by immediate reactions and delayed reactions. Depending on what type of healthcare or human services work you do will depend on what type of symptoms you’ll see. If you’re an emergency services worker like a paramedic or ER nurse you’ll be dealing with the immediate reactions. Most other healthcare facilities will be dealing with delayed reactions. It’s important to know and understand both because no two humans experience situations the same so we must have this broad understanding of trauma reactions.

Under the emotional reaction domain an immediate reaction may include numbness and detachment. Anxiety, fear, terror or hysterics. Guilt, which could include survivors guilt. Exhilaration as a result of surviving. Anger, sadness, helplessness, Feeling unreal or depersonalization such as feeling you are watching yourself are commonly reported. Other immediate emotional reactions include disorientation, feeling out of control, denial and feeling overwhelmed.
Some examples of delayed emotional reactions to trauma include: Irritability and/or hostility, Mood swings, Depression, Anxiety, phobias, Fear of trauma recurrence
Grief reactions, Shame, Feelings of fragility and/or vulnerability, Emotional detachment from anything that requires emotional reactions for example you don’t care or show emotion to significant and/or family relationships, conversations about self, discussion of traumatic events or reactions to them.
The next domain is related to the body’s physical reactions to trauma. Immediately following a traumatic event an individual can become nauseated or have gastrointestinal distress, sweating or shivering, muscle tremors or uncontrollable shaking, an individual may feel faint or actually pass out. There’s an increase in heart rate, respirations and blood pressure. There may be a greater startle response, extreme fatigue or exhaustion and depersonalization. Delayed physical reactions include: Sleep disturbances, nightmares, Somatization. Somatization is the unconscious process by which psychological distress is expressed as physical symptoms such as back, neck or stomach pain. Other delayed physical reactions include: Appetite and digestive changes, Lowered resistance to colds and infection, Persistent fatigue , Elevated cortisol levels, Hyper-arousal and Hyper-vigilance, Long-term health effects including heart, liver, autoimmune, and lung disease.

Now let’s cover the Cognitive domain and the types of reactions that can occur to our brains and thinking when subjected to trauma. Immediate cognitive reactions include: Difficulty concentrating, racing thoughts, rumination which means or replaying
the traumatic event over and over again. Distortion of time and space, for example the traumatic event may be perceived as if it was happening in slow motion, or a few seconds can be perceived as minutes or hours. Other reactions that can occur in this domain is having memory problems such as not being able to recall important aspects of the trauma. Delayed cognitive reactions include: Intrusive memories or flashbacks, reactivation of previous traumatic events, blaming oneself for the trauma, preoccupation with the traumatic event, difficulty making decisions, magical thinking which is a belief that certain behaviors, including avoidant behavior, will protect against future trauma. Other delayed cognitive reactions include that feelings or memories are dangerous. Trauma sufferers may also have generalization of triggers, for example a person who experiences being assaulted during the day-time may avoid being alone during the day. Suicidal thoughts are also a delayed cognitive reaction to trauma.
Now let’s move onto the behavioral domain and explore some of the immediate reactions that occur in our behavior due to a traumatic event. Immediate Behavioral reactions include: Startled reaction, restlessness, sleep and appetite disturbances, difficulty expressing oneself, argumentative behavior, Increased use of alcohol, drugs, and tobacco, Withdrawal and apathy and avoidant behaviors. Common behavioral reactions that are delayed include: Avoidance or withdrawal from relationships and other social interactions, events and activities, decreased activity level, engagement in high-risk behaviors, increased use of alcohol and drugs.

The final domain of reactions we’ll cover is the spiritual or existential reactions. Practices of spirituality along with thoughts about the meaning of life and why we exist is a part of this domain. Immediate existential reactions to trauma can vary significantly. Immediate reactions may include the intense use of prayer. Trauma victims who received help from others also report a Restoration of faith in the goodness of others. On the other end of the spectrum reactions may include: Loss of self-efficacy. Self-efficacy is the extent or strength of one’s belief in one’s own ability to complete tasks and reach goals. Other spiritual or existential reactions include despair about humanity, especially if the event was intentional. Trauma victims also report an Immediate disruption of life assumptions such as the fairness of life, safety, goodness and the predictability of life. Delayed existential and spiritual reactions to trauma include questioning such as “Why me? Why did this happen? There can also be reactions of cynicism and disillusionment. On the flip side trauma sufferers can have an increased self-confidence thinking and having thoughts of invincibility-a trauma victim may say, “If I can survive this, I can survive anything.” Other delayed reactions in this domain may include: Loss of purpose, Renewed faith, Hopelessness, Reestablishing priorities, Redefining meaning and importance of life. Reworking life’s assumptions to accommodate the trauma such as taking a gun safety or self-defense course to reestablish a sense of comfort and safety.
As you’ve just heard there are many types of reactions to trauma. No two individuals react the same. Did you notice that some reactions to trauma were actually positive and healthy such as taking steps to redefine meaning and importance of life. Other reactions such as alcohol and drug use are unhealthy ways to cope with the distressing and traumatic event. There are many factors and variables to consider when assessing and evaluating reactions to trauma. Being aware of all the various thoughts, behavior, and practices will help us to better serve those who have suffered a traumatic event and putting us on the path of being Trauma-informed.
We’ve just covered reactions to trauma and earlier we talked about the developing brain and how the infrastructure can be affected by the experiences and environments that are stressful, toxic and traumatic. In that same vein of childhood development we’re going to look at a research study called the Adverse Childhood Experiences Study. This section will blow your mind because so much of what we experience as kids can have lasting lifelong affects on our health.

6. THE ACE STUDY
I’m not sure if you’ve heard of the Adverse Childhood Experiences or ACE study before but really it’s research that everyone including your grandmothers should know about. If you haven’t heard of the ACE study before it will blow your mind. If you have heard of it this will be a good refresher. We talked earlier about trauma and toxic stress and how it can affect children developmentally. The ACE study builds on the fact that traumatic early life events have adverse effects but also highlights the ramifications and health effects decades later as an adult. To put it simply, the ACE study revealed that adverse or traumatic experiences in childhood are pretty common, even in demographics of society we typically don’t associate with trauma such as white middle-class. This study also showed that adverse childhood experiences are linked to every major chronic illness and social problem that the United States grapples with – and spends tons and tons of money on. This study changed the landscape because of the pervasiveness of ACEs in the huge number of public health problems, expensive public health problems such as depression, substance abuse, STDs, cancer, heart disease, chronic lung disease, and diabetes.
This study was the first time researchers had looked at the effects of several types of trauma, rather than the consequences of just one and as you’ll see the results were mind-boggling. Before we delve further into the study let’s take a few moments to take the ACE study together. I have to warn you that the questions are sensitive in nature and may be difficult for some of you out there. Pull out a sheet of paper…go ahead…you can pause me and come back, I’ll wait. [Act like, I’m pausing] Now that you have your sheet of paper number it 1 to 10. I’m going to ask you ten questions and For every yes to a question right down the number 1. Are you ready here we go.
Before your 18 birthday have any of the following happened to you. Did a parent or other adult in the household often or very often… Curse at you, insult you, put you down, or humiliate you? or Act in a way that made you afraid that you might be physically hurt? If Yes to any of those questions put down a number 1. If it is a no then leave it blank. Question number 2: Did a parent or other adult in the household often or very often… Push, grab, slap, or throw something at you? or Ever hit you so hard that you had marks or were injured? Question 3: this one is a little sensitive-Did an adult or person at least 5 years older than you ever… Touch or fondle you or have you touch their body in a sexual way? or Attempt or actually have oral, anal, or vaginal intercourse with you?
Question 4: Did you often or very often feel that … No one in your family loved you or thought you were important or special? or Your family didn’t look out for each other, feel close to each other, or support each other? Five: Did you often or very often feel that … You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it? Six: Was a biological parent ever lost to you through divorce, abandonment, death or other reason?

Seven: Was your mother or stepmother: Often or very often pushed, grabbed, slapped, or had something thrown at her? or Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit over at least a few minutes or threatened with a gun or knife? Eight: Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs? Nine: Was a household member depressed or mentally ill, or did a household member attempt suicide? And lastly number 10: Did a household member go to prison?
Statistically for some of you out there these questions were difficult because you’ve experienced these things. I’m sorry for that. Now that you have your responses add up all the Yes answers. I’ll give you a few seconds. The total tallied number from the questions I just asked you is your ACE score. But what does your ACE score mean? You’ll have to wait bit. We’ll get to that a little bit later on in the course. Just keep your score in mind.
To help you appreciate the significance and context of the ACE study I wanna give you a little bit of its backstory. First, let me introduce you to this kick arse doctor, Vincent Felitti, he just looks like a Vincent doesn’t he? Look at that hair, it’s just gorgeous don’t you think. [Graphic of Dr. Vincent] In 1985 Dr. Felitti was the chief of the Department of Preventative Medicine in San Diego, California. His department was one of the largest departments of its kind in the world and every year more than fifty thousand people were served. He was running an obesity clinic for people who were 100 to 600 pounds overweight and were at serious risk of suffering some major health problems from their weight conditions. Dr. Felitti served thousands of obese individuals through the years. He did great work but he noticed that over the years that his patients were dropping out of his program at kind of an alarming rate. Dr. Felitti looked at his clinic statistics and he couldn’t figure out why so many people would drop out of his program after losing a lot of weight. His patients were making good progress people were losing hundreds of pounds of weight but they were quitting. Dr. Felitti was like wait a minute- these patients were motivated, they were willing to take part and participate and well on their way to getting healthy. The weird thing was the dropout rate was 50%. If you can’t do the math that’s one out of two patients would just give up after dropping tons and tons of pounds. This was a head-scratcher for Dr. Felitti. He was thinking to himself…what the heck is going on here? He was ticked off and so began his mission to find out why one in two of his patients were dropping out.

Dr. Fellitti’s quest to find out why his patients were quitting his program became a twenty-five year quest that turned into multiple researchers getting involved as well as the United States government’s Centers for Disease Control. Dr. Felitti’s quest not only involved tons of researchers but also involved over 17,000 research participants. In research terms that is a lot of people. An n of 17,000. In research you want to have as large of a number of study participants as possible to make your study more credible and representative of the population and generalizable. If I have a sample size of 10 people or an N of 10 the margin of error is 31.6%. I won’t get into the math right now but my margin of error decreases as I have a bigger number of participants. A Sample size of 50 gives me a margin of error of 14.1% Sample of 10,000 and my margin of error is 1%. Which means the results of a study are representative of the population. So, this initial ACE study had over 17000 people studied which means this is a really credible study.
Let’s move on from our little mini research course. Sorry about that tangent.
So where were we? Oh yes, Dr. Felitti was on this quest to find out why people were quitting his obesity clinic. After multiple dead ends and years of trying to find the answers he decided to do some face-to-face interviews with a few hundred of the obese individuals who dropped out of his program. His interview questions were fairly routine and he used a standard set of questions for all his interviews such as, “How much did you weigh when you were born?” “How much did you weigh when you entered elementary school, middle school, high school?” “How old were you when you became sexually active?” For a while there were no huge revelations or earth shattering answers or clues to help Dr. Felitti see why people were dropping out of his weight loss clinic. But one day by accident. He got a breakthrough. With one of his patients he asked those routine questions we just went over but by accident instead of asking “how old were you when you became sexually active” he misspoke and asked, “How much did you weigh when you became sexually active?” The person he asked this question to was a woman and her answer was 40 pounds. At first this didn’t make sense to the Doctor. The woman weighed forty pounds when she became sexually active? He scratched his head and mistakenly asked the question again, “How much did you weigh when you became sexually active.” The woman started crying and she burst into tears and said she became sexually active at four years old because she was sexually abused by her father. Dr Felitti didn’t necessarily know what do with the information he received so he continued on in his study and a little over a week later he ran into the exact same thing with another client reporting being sexually abused at a young age.

Over and over again he kept getting report of these past obese clinic patients being sexually abused at a young age. Dr. Fellitti wondered if the way he was asking his questions were injecting some kind of bias so he asked five of his colleagues to ask the question about what weight people were when they became sexually active. His colleagues interviewed over 280 people and the majority of them were abused sexually in their childhood. It was sad but also astonishing, but what did it mean? What does it mean that all of these obese individuals were sexually abused and quit coming to the obesity clinic after they had been making good progress. Well, Dr. Felliti didn’t start to get his answer until he interviewed a patient who was raped. This particular women reported after answering the question about weight and sexual activity stated that she gained 105 pounds after being raped because she said…”Overweight is overlooked and that’s the way I need to be”. At this point the Doctor was starting to see the emerging theme. Patients being interviewed were saying things such as, “I was skinny and always got beaten up, now I’m fat and I don’t get messed with.” Other sexual assault victims reported similarly that weight was a defense mechanism and made them feel invisible to men. Not eating, dieting and Shedding pounds and becoming normal weight caused fear, depression, and anxiety. One patient who was abused sexually as a child and three hundred pounds overweight stated that every time she lost weight and someone commented on her beauty she would panic and gain all her weight back.
These revelations about overeating and obesity started to change mindsets about coping mechanisms and opened up a dialogue about the way we interact and judge those with these bad habits. When we tell someone to stop overeating because it will harm them in the long run doesn’t register because overeating may be a normal response to their trauma that contains multiple levels of past complex and difficult experiences. So Dr. Felleti made the connection, Childhood traumatic events lead to these coping mechanisms of overeating resulting in obesity and in inability to continue with weight reduction therapy.

Well, at this point Dr. Felitti has some pretty good information about trauma and later in life problems of obesity. You would think the medical community would be interested in his results. Unfortunately, his findings weren’t accepted with wide open arms. But one thing led to another and Dr. Felitti was introduced to another Kick arse researcher at the Centers for Disease Control and Prevention, Dr. Robert Anda. [Graphic of Dr. Anda] Dr. Anda was working on his own research project about hopelessness, depression and coronary heart disease. In his studies Dr. Anda was finding out that depression and hopelessness weren’t random and wanted to study what the causes were. It seems like the two doctors were a perfect combo, a kind of Batman and Robin duo trying to find out more about the root causes of commonly occurring health issues in our society. They found the perfect setting to start their collaborative research to help them understand how childhood events might affect adult health. They conducted research at the Kaiser Permanente Department of Preventive Medicine. Of the 50,000 people who came through that Department each year, 17,421 people agreed to take part in a study by Dr. Felitti and Dr. Anda. This Department was a great setting for this study because patients received comprehensive medical evaluations.
We already took the ACE test and as you know The questionnaire that Dr. Felitt and Anda came up with questions pertaining to three types of abuse – sexual, verbal and physical. And five types of family dysfunction – a parent who’s mentally ill or alcoholic, a mother who’s a domestic violence victim, a family member who’s been incarcerated, a loss of a parent through divorce or abandonment. Also included were questions related to emotional and physical neglect, for a total of 10 types of adverse childhood experiences, or ACEs. The initial surveys began in 1995 and continued through 1997, with the participants followed for more than fifteen years. That’s a long time.
After all those years of research and hard work the data was compiled and the results were sent to Dr. Anda. The story goes that he actually started crying when he got the results because the data showed how much people had been suffering due to past trauma. Remember this is the first time researchers looked at the effects of several different types of trauma rather than just the consequences of one type. The results of the research were mind-blowing.
The first mind-blowing result was there was a direct link between childhood trauma and adult onset of chronic disease, as well as mental illness, doing time in prison, and work issues, such as absenteeism. The second mindblower was that Adverse Childhood experiences are pretty darn common. About two-thirds of the adults in the study had experienced one or more types of adverse childhood experiences. Of those, 87 percent had experienced 2 or more types. And remember, the study participants were middle class and most of them went to college so they weren’t exactly from backgrounds that you would perhaps typically equate with hardship like being poor or living in violent areas such as inner cities. Also, ACEs didn’t happen in isolation. If someone had an alcoholic father they probably also experienced verbal or physical abuse.
The third results of the ACE study that were mind-blowing were that the higher the ACE score the higher a person was at risk for medical, mental and social problems in adult life. Let me show you this. [Graph 1-reveal smoking and lung disease to ACE score] If I told you this graph shows the correlation or relationship between smoking and lung disease. You would be like duh, right. It’s common knowledge that smoking significantly increases the rates of lung disease. But what if I told you this graph isn’t showing smoking and lung disease. It’s showing you the relationship between ACE scores and lung disease. Can you believe it. Compared with people with zero ACEs, those with four categories of ACEs were 390 percent more likely to have chronic obstructive pulmonary disease. That number is astronomical.

If I said that this graph is showing the relationship between alcoholism and liver disease, again you wouldn’t bat an eye right. You would say duh, you drink a ton of alcohol for years and years and years that will eventually cause liver damage. But what if I told you that this is actually showing ACE scores and liver disease. There is a pretty strong relationship there. In fact, Compared with people with zero ACEs, those with four categories of ACEs had a 240 percent greater risk of hepatitis. That’s crazy, right? Here’s a graph showing Ace Scores and long-term chronic depression. Let’s break it down by gender to see if we see the same type of relationship. Again, we see here that the more ACE scores you have the higher the rates of depression. It’s quite fascinating.
Are you still a little skeptical. Let’s show you a few more here. Let’s take the topic of risky behavior such as the use of injectable illicit drugs like heroin. As you know engaging in this type of behavior can lead to HIV, Aids or some other type of blood borne illness for example, Hepatitis C. Let’s see if there’s a relationship between ACE scores and engaging in this type of risky drug use behavior. Here you can see the relationship between the ACE score and those who have ever injected drugs. Quite a compelling correlation here. Another risky behavior that can lead to a host of illnesses such as HIV, Aids and Sexually transmitted infections is having multiple sexual partners. This graph is showing the relationship between ACE scores and those who have had 50 or more sexual partners. Again, the lower the ACE score then lower the number of sexual partners the higher the number of ACES the higher the number of those with sexual partners in excess of 50.
Let’s look now at a few mental health-related ACE scores. Here you see the relationship between ACE scores and suicide attempts. Again a pretty noticeable trend that ACE Scores and suicide correlate. Here’s another category related to ACE scores and social function. Social function includes number of days absent at work, financial hardship and serious problems performing job requirements. This graph shows ACE scores and absenteeism from work. In this case absenteeism is defined as missing over 2 days per month. Here’s the graph- Do you see the relationship here. How about serious financial problems. It just goes on and on- ACE score and Teen Pregnancy [Graph 9- Teen Pregnancy], ACE score and Perpetrating Domestic Violence [Graph 10- Domestic Violence], ACE Score and antidepressant use, ACE scores and encounters with the criminal justice system. People with high ACE scores are more likely to be violent, to have more marriages, more broken bones, more drug prescriptions,, more auto-immune diseases.

Well, are you convinced yet about the importance of being aware about ACEs. The correlations and relationships between the ACE score is hard to deny. In fact, Dr. Anda said some of the increases are of a size that you rarely ever see in health or epidemiological studies. You can see why Dr. Anda cried when he saw the results of the data. To a large extent people’s behavior, emotions, mental health and future are related to the ACE score. I do want to interject here, so you don’t get too depressed, is that all humans have the capacity to overcome hardships and adversity. With proper services and support as well as strong social networks and relationships many difficulties of childhood can be dealt with. So, don’t get discouraged especially those of you who have a high ACE score. You’re not depressed about this are you? I hope not. If you’re ok we’ll keep moving on.
So what’s the story here. We’ve covered the brain biology and now the ACEs and if you haven’t picked up on it yet that a pretty compelling and intriguing story has developed that needs to be paid attention to. What’s the story. Well, let’s map it out for you by using the Center for Disease Control and Prevention’s ACE Pyramid. This pyramid shows the whole life perspective from conception to Death.
Children who experience adverse childhood events and thus live there lives in toxic stress-filled environments their bodies are constantly in a hyperarousal mode of fight or flight, Freeze or submit mode. Their brains and bodies are being flooded with stress hormones such as cortisol and adrenaline and the very architecture of their brains are being affected and they aren’t able to focus on learning and developing the necessary skills for adult life. The cascade of events continues with the child falling behind in school, not trusting in others and thus failing to develop healthy relationships with peers, teachers and adults. The story goes on with the child feeling shame, guilt, sadness, frustration, anger and turning to coping mechanisms such as tobacco, drugs, inappropriate sexual behavior, high-risk behavior so on and so forth. The impairments socially, emotionally, cognitively translate to poor health and disease, disability and social problems and sadly ending in an earlier than expected death.

If you haven’t figured it out yet this study is huge and the results should shape the way we not only deal with the people we take care of but our own personal lives. Now that you have the knowledge about the fact that trauma can be generational and perpetuated through our actions and lifestyles, it should cause us to stop and say, Holy crap, maybe I should do my part to decrease ACE scores. This study changes the landscape of the healthcare and human services industry because the ACEs are so pervasive across all populations. Remember that the ACE study’s participants were average Americans. Eight percent were white, including Latino, 10 percent black and 10 percent Asian. They were middle class middle-aged, and 74 percent were college-educated. How much higher do you think ACE scores are in populations and locations that experience a lot of violence, crime and are impoverished?
Being aware of the ACE study should tune you into the fact that statistically speaking 1 in 6 people that you take care of or interact with in the healthcare or humans services sector have an ACE score of 4 or more and 1 in 9 have an ACE score of 5 or more. So everyday you work, depending on the type of job you have you are directly or indirectly working or interfacing with people who have ACE scores of 4 or more which puts them at risk for serious health issues and early death. Shouldn’t this change our perspectives and spur us on to providing the best and highest quality care possible that is trauma-informed. It’s absolutely essential that we help the people we serve to be supported and get plugged into the correct resources and prevent adverse childhood experiences. All of us play a part. It isn’t just a counselor, social worker or psychiatrists job. All hands are needed on deck to provide an environment that understands trauma and knows the impact it has on all individuals. We need to change our systems and it isn’t just healthcare but the educational, criminal justice, public health system and workplaces. It’s going to take concerted efforts by all of us to prevent this public health disaster.

Sadly, widespread understanding and adoption of the ACE study hasn’t occurred yet. Most of the work that’s been done in the past focuses on the stress from individual traumatic events suffered and the focus hasn’t been placed on dysfunctional families or preventing Adverse Childhood experiences through system changes.
It’s crazy that for the most part the healthcare community at large has practically ignored the ACE study. There are a few exceptions but it’s our job to inform the places where we work about the importance of the ACE study and how we can use the information and data to create environments and cultures that are trauma-informed. It’s up to us to ensure that ACEs decrease so that the next generation has the opportunity to live a healthy life and not one that’s filled with the pain and torment of a difficult and toxic childhood. We’ve given you the background of the ACE study and shown you the long-term effects on health. Those graphs show a sad story that childhood experiences must not be ignored. Now we want to uncover some of the principles and tenets of trauma-informed care.

7. TRAUMA-INFORMED CARE
So what the heck is Trauma-informed Care? I’m glad you asked. Simply put trauma informed care recognizes that when a patient or client comes to you for treatment they may have been trapped and suffering from some type of traumatic event.
Emotional and psychological trauma often goes unnoticed, ignored or unaddressed. Organizations and systems looking to practice trauma informed care must focus on the unaddressed, more continuous trauma behind that experience before it leads to chronic disease, emotional and mental problems. Trauma informed care can be defined as a strengths-based framework that is grounded in an understanding of and responsiveness to the impact of trauma…that emphasizes physical, psychological, and emotional safety for both providers and survivors…and, that creates opportunities for survivors to rebuild a sense of control and empowerment.
As we’ve learned, exposure to trauma is relatively common and highly disabling. We know that traumatic experiences not only significantly impact mental health but also can cause health problems, substance abuse issues and contact with the criminal justice system as well as early death. In this section we’re going to introduce you to the concept of becoming trauma-informed. Providing trauma-informed care is powerful and can set an individual on a path toward healing from past traumatic experiences. Trauma-informed care seeks to understand the whole life context on a person and not just their symptoms or complaints. Building Trauma Informed Care Systems requires a Paradigm Shift and it fundamentally changes the way we interact with patients and clients. Our questioning and inquiries change from “What’s wrong with you?” to “What happened to you?” The question, “What happened to you?” Conveys compassion and empathy. The question, What’s wrong with you can be shaming and blaming as well as bring up feelings of guilt which can thwart relationships with the people we are trying to take care of. Listening and understanding the life stories of our patients is a powerful and therapeutic first step in implementing care that is sensitive and understands the impact of trauma. Patients who feel genuinely listened report feeling valued and cared about. In some cases, listening and valuing someone may be the most powerful and effective intervention we can offer.
In order to meet the unique needs of those who have experienced trauma, programs, healthcare systems and services need to proactively respond compassionately and empathetically to the trauma survivor. To be trauma-informed means that programs, agencies and healthcare facilities must provide services through the lens of trauma in order to create environments and cultures that can serve the needs of those who have been traumatized. We need to stress the fact here that every single agency and organization should be trauma-informed. I believe it should be an additional vital sign to ask about past trauma and then direct and tailor services as appropriate. Traumatic experiences are so common that we need to practice what those in child protective services call Universal Precautions which means that everyone we interact with we should assume they have had a traumatic experience and should thus tailor our care accordingly. Institutions and organizations that utilize trauma-informed philosophy to inform their services have seen positive outcomes for both patients and providers of care.
We have to make a distinction here between trauma-informed care and trauma-specific care. Trauma specific care includes performing specific therapies or treating specific symptoms related to trauma. Trauma specific care is specialized and performed by experts and professionals trained to perform trauma therapy. So what the heck are we talking about then if we aren’t talking about therapies?

Trauma-informed care refers generally to a philosophy that integrates Awareness and understanding of trauma. So far in this course we’ve made you aware and increased your understanding about several different types of trauma as well as its prevalence and effect on health. Congratulations, you are now trauma-informed. Trauma-informed care also provides a framework or model that guides and directs the organization and behavior of a system, program or facility. But being trauma-informed also recognizes the impact and responds appropriately to how trauma has affected our own lives as well as fellow co-workers. Just because you and I work with patients and clients doesn’t mean that we have had perfect lives. I’ve had trauma in my life and being aware of that and taking steps to recover is a critical aspect of being trauma-informed. We’ll talk about this more a little bit later on.
At the very minimum trauma-informed care services try to do no harm or anything that can be re-traumatizing or blames patients for their efforts to manage their traumatic reactions. Re-traumatizing can include readily using restraints or threats of restraint use. Medical procedures can also be re-traumatizing especially when performed without proper and compassionate explanation from medical personnel.
As we’ve discussed earlier, implementing trauma-informed care requires a philosophical and cultural shift within an organization or service.
Becoming trauma-informed is critical and can help direct a patient or client start on a path toward health and wholeness.
To create Trauma-informed care settings there are 4 Key Assumptions that provide the framework to build. Upon the 4 Key assumptions are 7 Principles and out of the principles they are Ten Domains of Implementation. I know it sounds a little confusing so let’s break down the three different parts shall we.
Let’s start with the 4 key elements or assumptions that are essential in providing and incorporating trauma-informed care. The 4 Rs stands for Realize, Recognize, Respond, and Resist Re-Traumatization.

The first R is realization. Realizing the prevalence or knowing how common trauma is and that their are many people who have suffered varying degrees of it. Trauma-informed services are informed about and sensitive to trauma-related issues present in trauma survivors as well as their families, groups of people and the community at large.
In order for a healthcare system, organization or agency to be respond to those who’ve been traumatized in an effective manner every team member must understand trauma and its potential impact upon an individual. It’s important that everybody, that means environmental services, receptionists, dietary staff and others be informed along side other members of the healthcare team. In order to provide the very best care that is compassionate it must be collaborative and pull from the strengths of everyone. An individual who suffers from the effects of trauma is influenced by their particular experiences and it affects the way they engage with services, staff, other patients, and responsiveness to guidelines and interventions.
The second R is recognize. Recognizing the signs and symptoms of trauma and how trauma affects all individuals not only patients that you see but those involved in the delivery of care such as co-workers, administration and ancillary staff is key. Trauma-informed systems and aim to mitigate the effects of trauma within the whole department, organization or system. Every member of an organization must be aware about trauma and its effects. Programs and organizations that are trauma-informed recognize the pervasive and long-term impact of all trauma as well as adverse childhood experiences. Organizations who have staff that are Trauma-informed understand the effects of traumatic life events on human development, the common coping mechanisms, strategies and adaptations used by trauma survivors. Additionally, those who hold to this principle have a basic knowledge and understanding about effective treatment approaches and tool for those who have experienced trauma. Recognizing the impact alone of trauma and the difficulties a survivor faces helps to validate the trauma victim. Validation helps the victim feel safe, encouraged and can restore a sense of hope.
The third key element is responding. Once you are aware of the trauma and recognize its influence upon a victim you must respond accordingly to those who have been traumatized in a caring, compassionate and therapeutic manner. In order to respond appropriately all members of an organization must be trained to be therapeutic. You don’t have to be a therapist to be therapeutic. You just have to respond appropriately with dignity and respect to the trauma victim.
The 4th R Is Resist Re-traumatization.

Resisting Re-traumatization entails that service providers recognize and understand the potential for re-traumatization during treatment or care delivery. Remember, feeling powerless is a central in those who have been traumatized. When you understand the abuse of power inherent in trauma victims, it becomes clear that the power difference between the person seeking help and the person offering it will be threatening. Often times we as healthcare and human services providers get on a power trip and want to show people who’s boss. Have you ever felt that way? Patients who have been victims of trauma will feel this power differential and it will hamper the relationship and the ability to provide care effectively. If we as service providers understand the potential for re-traumatization and the trauma victims fear about it and the expectations of it, then it is possible to work to protect against re-traumatization. Sometimes we are well-meaning and unknowingly can re-traumatize someone. For example when we perform Invasive procedures or do some type of task in an insensitive manner it may trigger trauma-related symptoms. Being aggressive, bossy or confrontational can trigger memories of trauma. Trauma victims may become hostile, angry or shut down emotionally or dissociate when triggered.
In this section we covered the 4 assumptions of Trauma-Informed Care. They were the 4 R’s of Realization, Recognize, Respond and Resist Re-traumatization. In the next section we will cover the six core principles of Trauma-Informed Care.
8. PRINCIPLES OF TRAUMA-INFORMED CARE
There are several Core Principles of Trauma-Informed Care. We’ve just talked about the four Key Assumptions of Realize, Recognize, Respond, and Resist Re-Traumatization. Now let’s cover the six core principles. The key principles give you a goal to obtain. They aren’t a set of prescribed set of procedures or practices. Take the principles and tailor them to your setting or agency.

Principle one is Safety. Throughout the organization, staff and the people you serve, whether children or adults, should feel physically and psychologically safe. Providing safety is an important aspect of Trauma-informed care. It is critical to provide and that is done by helping patients to recognize how they view safety. Your idea of safe may be a lot different than your patients view of safety. Work with the individual you’re taking care of to create a safety plan to reduce threats, and think through how they can become safer physically, psychologically and socially.
Principle two is Trustworthiness and Transparency. Organizational operations and decisions should be conducted with transparency with the goal of building and maintaining trust with clients and family members, among staff, and others involved in the organization. Healing happens in relationships Believing that establishing safe, authentic, transparent and positive relationships can be corrective and restorative to survivors of trauma is what this principle is all about. Now, I know it can be hard to be positive and caring to everybody you take care of. It’s hard when someone cusses you out and calls you names or is downright rude. But if you just think about the fact that they may have deep seeded pain and trauma from their past should help you to see past someone’s rough exterior. Remind yourself that a individual’s pain is probably dictating their behavior and isn’t a reflection on you or your performance as one who provides care. Do your best to develop a relationship that is professional, courteous and caring. You don’t have to be someone’s best friend but just remember the golden rule- treat others the way you would want to be treated.
Principle three is Peer Support. Peer support and mutual self-help from fellow trauma survivors are key vehicles for establishing safety and hope, building trust, enhancing collaboration. Utilizing the stories and lived experience of those who have experienced trauma can help promote recovery and healing in others. It’s absolutely essential to understanding that recovery is possible for everyone regardless of how vulnerable they may appear; instilling hope by providing opportunities for consumer and former consumer involvement at all levels of the system, facilitating peer support, focusing on strength and resiliency, and establishing future-oriented goals are all a part of this principle. Trauma Informed Care involves looking to the future to help patients envision what they want so they may rise above the pain of trauma.
Principle 4 is Collaboration and Mutuality. Promoting democracy and equalization of the power across departments and programs is essential to providing trauma-informed care. The sharing power and decision-making across all levels of an organization, whether related to daily decisions or in the review and creation of policies and procedures helps develop effective services but also gets buy-in and ignites passion in all sectors of an organization. Importance is placed on partnering and the leveling of power differences between staff and clients and among organizational staff from clerical and housekeeping personnel, to professional staff to administrators, demonstrating that healing happens in relationships and in the meaningful sharing of power and decision-making. The organization recognizes that everyone has a role to play in a trauma-informed approach. You don’t have to be a therapist to be therapeutic. It’s everyone’s job to actively participate in developing a therapeutic system.
Principle 5 is Supporting Control, Choice and Autonomy. This principle is all about empowering a trauma victim. The feeling of powerlessness is so central to trauma that helping patients and consumers regain a sense of control over their daily lives and build competencies that will strengthen their sense of autonomy is a must. Also, keeping them well-informed about all aspects of the system, outlining clear expectations, providing opportunities for to make daily decisions and participate in the creation of personal goals, and maintaining awareness and respect for basic human rights and freedoms all is a part of this principle. The ultimate goal of this principle is to expand the trauma victims resources and networks of support so there is less and less reliance on professional services. This principle also endeavors to help victims move beyond recovery and healing and become advocates and supporters of other victims.

Principle 6 is Cultural, Historical, and Gender Issues. It’s key to understand how cultural context influences one’s perception of and response to traumatic events and the recovery process. Cultural competence also includes respecting diversity, providing opportunities for patient, clients or consumers to engage in cultural rituals, and using interventions respectful of and specific to cultural backgrounds. This principle also emphasizes that the organization actively moves past cultural stereotypes and biases that are based on race, ethnicity, sexual orientation, age, religion, and gender-identity. To put this principle into practice settings and agencies must offer, access to gender responsive services and also leverage the healing value of traditional cultural connections. Policies, protocols, and processes that are responsive to the racial, ethnic and cultural needs of individuals served; and recognizes and addresses historical trauma must also be enacted when following this principle.
We’ve covered the 4 Assumptions so far and the 6 principles of Trauma-informed care. So what are some of the practical implementation steps we can take? How do we put all these assumption, principles and theories into practice. That’s a good question an I’m glad you asked. Implementing is hard. Putting these ideas into practice can pose difficulty because they can take some serious time, effort and money. There are ten implementation domains which will cover in our next segment.

9. IMPLEMENTATION DOMAINS
So far we’ve covered the 4 assumptions to Trauma-informed care and have talked about the principles. Now we’ll talk a little bit about the 10 implementation domains. We’ll only briefly highlight these domains because implementation is such a huge arena. For now, its important for you to get a basic understanding of the ten domains.
The first domain of implementation is Governance and Leadership: The leadership and governance of the organization must support and invest in implementing and sustaining a trauma-informed approach. Without leadership involved a trauma-informed environment and culture can’t survive. Domain two is Policy: I know you hate the word policy but there must be standards written to ensure the principles of a trauma-informed approach are followed day-in and day-out. Procedures and protocols must be set in stone and be able to be accessed and pointed to when there is any questions or concerns.
Domain three is dealing with the Physical Environment of the organization. It’s critically important that an organization ensures that the physical environment promotes a sense of safety and collaboration. Staff working in the organization and individuals being served must experience the setting as safe, inviting, and not a risk to their physical or psychological safety. The physical setting also supports the collaborative aspect of a trauma informed approach through openness, transparency, and shared spaces.
Domain 4 is super duper important and is a key value and aspect of a trauma-informed approach that differentiates it from the usual approaches to services and care. The domain includes ENGAGEMENT AND INVOLVEMENT OF PEOPLE IN RECOVERY, TRAUMA SURVIVORS, PEOPLE RECEIVING SERVICES, AND FAMILY MEMBERS RECEIVING SERVICES: These groups must have significant involvement, voice, and meaningful choice at all levels and in all areas of organizational functioning during program design, implementation, service delivery, quality assurance, cultural competence, access to trauma-informed peer support, workforce development, and evaluation. Involving others will ensure that your trauma-informed service will be beneficial to the end-users.
Our next domain is called CROSS SECTOR COLLABORATION: Collaboration across different sectors of healthcare and human services disciplines is critically important. There must be a shared understanding of trauma and principles of a trauma-informed approach amongst providers and caregivers. While a trauma focus may not be the stated mission of various service sectors, understanding how awareness of trauma can help or hinder achievement of an organization’s mission is a critical aspect of building collaborations. People with significant trauma histories often present with a complexity of needs, crossing various service sectors. Even if a mental health clinician is trauma-informed, a referral to a trauma-insensitive program could then undermine the progress of the individual.

We are going to delve into this domain a little bit later because it is something you can start performing immediately. The domain of SCREENING, ASSESSMENT, AND TREATMENT SERVICES is also critically important. For years experts have been telling providers to screen and assess for trauma but unfortunately it has taken root yet. It is important that we are trained in screening, assessing and referring and that it is based on the best available evidence and science. We also need to perform these interventions in culturally appropriate ways that reflect principles of a trauma-informed approach. Trauma screening and assessment are an essential part of the work. When trauma-specific services are not available within the organization, there should be a trusted, effective referral system in place that facilitates connecting individuals with appropriate trauma treatment. In a little bit we’ll investigate this domain a little bit more.

TRAINING AND WORKFORCE DEVELOPMENT is our next domain. Hey, this is what this class is all about. On-going training on trauma and peer-support are essential. This domain includes the fact that organization’s human resource system incorporates trauma-informed principles in hiring, supervision, staff evaluation and procedures are in place to support staff with trauma histories and/or those experiencing significant secondary traumatic stress compassion fatigue or vicarious trauma, resulting from exposure to and working with individuals with trauma.
Domain eight deals pertains to PROGRESS MONITORING AND QUALITY ASSURANCE. An agency or program that is trauma-informed must have ongoing assessment, tracking, and monitoring of trauma-informed principles and use effectively evidence-based trauma specific screening, assessments and treatment. Our next domain is FINANCING. Money is important isn’t it? Financing structures should be designed to support a trauma-informed approach which includes resources for: staff training on trauma, key principles of a trauma-informed approach; development of appropriate and safe facilities; establishment of peer-support; provision of evidence-supported trauma screening, assessment, treatment, and recovery supports; and development of trauma-informed cross- agency collaborations. Finally, for our last implementation domain there must be a system of EVALUATION that measures and evaluates the implementation and effectiveness of trauma-informed care services and programs.

We just covered the 10 domains of implementation but I want to go back and highlight the Assessment and Screening domain. Recognizing the centrality of trauma in an individual’s life is critically important during assessment and screening. It is our belief and desire that all healthcare and human service disciplines assess and screen for a history of past trauma. This includes hospitals, clinics, jails and all other types of agencies and programs. Conducting screening as well as more in-depth assessment in a trauma-informed manner involves: Understanding that patients or clients may be uncomfortable answering questions because of distrust of others in general or of service providers in particular. Remember, victims of trauma have a history of having their boundaries violated and may fear that the information could be used against them in some manner or they will be violated somehow. Patient surveys have shown they want their healthcare providers to ask about histories of abuse and violence. Many of you may be thinking that you shouldn’t pry or you may bring up past pain that would be difficult to deal with. Remember, talking about past traumatic experiences can be very healing in and of itself. There are at least two reasons why trauma assessments don’t occur. One is the underreporting of trauma by survivors and two, under cognition of trauma signs and symptoms from us, the healthcare or human services provider.
During a Trauma assessment it’s important to: Identify symptom occurrence- many times people have unexplained complaints such as pain but are really associated with the past traumatic experiences. During the assessment you must Ask about prior trauma history or histories and then work to Identify trauma etiology or cause. A trauma assessment also includes: Identifying co-occurring mental health symptoms and Identifying commonly occurring conditions. Finally you must Explore health risk behaviors and risk factors. Assessments also involve clearly communicating the right for an individual not to answer questions. Remember, you want to empower the victim not make them feel they are powerless without choice or autonomy. Another point to remember is clearly communicating your reasons for asking questions that aren’t apparently related to the problem someone is seeking service. Be honest and tell the patient why you are asking certain questions and that you care about helping them recover.
When appropriate utilize screening tools to help with your assessment. Screening tools are great and can help with getting to the root of some issues. Trauma screening refers to a brief, focused inquiry to determine whether an individual has experienced specific traumatic events. An effective trauma screening does not need to be complicated; it does need to be clear though. There are a number of screening tools available that can be accessed through reputable trauma-informed care services. Take great care to utilize tools that are applicable and tailored to your setting.

When a patient tells you about their traumatic experiences it can be very difficult to hear and then to know what to do with that information. In our next section we’ll cover some skill necessary in response to trauma disclosures. Responding appropriately has significant impact upon the individual who shares about the experiences.
The eight principles of Trauma-informed care that we just described apply in all settings. The way some of these principles are enacted and applied might be different depending upon the type of organization or facility you work in. Understanding the life context of a victim along with their strengths, adaptations and coping mechanisms is important when developing environments and cultures that are trauma-informed. Restoring power, developing trust and ensuring safety is essential to helping a patient recognize and recover from the effects of trauma. We all need to practice universal precautions when interacting not only with patients but fellow co-workers, family members and friends. I hope that you will use this principles to ensure that where you work is trauma-informed so that you can provide services early and appropriately to help an individual who has been a victim of trauma.

10. RESPONDING TO TRAUMA DISCLOSURES
So, what happens when someone opens up about trauma and discloses some very sensitive information. Often times we might be uncomfortable with some of the information conveyed to us. Here are a few responses you can make:
“I’m sorry you were hurt in that way.”
“What happened to you was not your fault.”
“You deserve help in dealing with something so difficult. Would you like me to connect you with someone who can talk to you about this?”
“Let me know how I can make you more comfortable as I take care of your medical needs.”
Caring, appropriate and empathic responses to those who share about their past traumatic experiences can be beneficial and healing to the victim. This is because the way we respond to a patient, client, co-worker or friend about their past trauma has a huge bearing and influence how the survivor heals. We must take great care and utilize compassion during these types of painful conversations. If we respond inappropriately we can hinder the healing process that talking about Trauma brings.
I think we all want to be supportive, encouraging and compassionate, right but when someone tells us about their past areas of pain we can feel scared, uncomfortable or intimidated and not know what to do or say. People may not want to talk about trauma for a number of reasons such as shame, guilt, fear of disbelief, fear of blame, fear of stigma or fear of harming loved one and for other reasons. Silence is a part of the problem of trauma. Sharing or disclosing the past traumatic experiences is therapeutic and can be healing. When someone tells you about their trauma you can provide support in a number of ways such as giving them information, resources and other generic supports. Your response can decreases costs related to outcomes of trauma, end stigma, improve well-being and prevent others form being traumatized. The success of helping a victim of trauma depends on your response.
Many of us are uncomfortable interviewing about histories of trauma. But remember, this can be a huge step towards helping somebody get on the path toward recovery and healing. Trauma-informed assessments and screenings are opportunities not only for essential information gathering but for beginning the development of safe, trusting, and collaborative relationships between trauma survivors and care providers.

11. TRAUMA-INFORMED CARE: QUICK TIPS
You’ve gotten a lot of great information so far and maybe it feels a little bit too overwhelming to incorporate all of it or to remember. So, what are some of the quick things you can do when interacting with someone who has had past trauma.
First ask Practice Universal Precautions and then ask yourself: Is what I am doing respectful and trauma-informed? Am I treating others the way I want to be treated?
Remember that depending on the type of trauma a victim may be struggling with one are all of the following: powerlessness, distrust and betrayal. Everything you do needs to work toward establishing safety, power and trust.
Here are a few good nuggets and tips to follow:
Always greet the individual you are taking care of in a professional, courteous, friendly and caring manner.
Ask what you can do to assist the individual-find out their needs,
Ask about Prior Trauma
Respond to Trauma Disclosures appropriately
Communicate care and concern- Facial expressions go a long way. Smile, use open body language, look into people’s eyes. Make sure your body language is receptive. Do I really have to tell you this?! You know how to convey care and concern, right. Then why don’t we do it?
Avoid passing judgment
If a person is not ready to talk, don’t force the conversation. Rather keep the door open for a later time. Maybe you can say, “I see that’s making you feel uncomfortable why don’t we follow back up with that later?”
Offer support and validation
Resist interrupting the patient
Explain what you plan to do. Say, “I’m going to give you a shot. It goes in your behind. I will take care not to expose you unnecessarily.
Ask Permission, “Would it be ok for me to give you this shot now?”
Check in regularly. Say, “Hey, is everything going alright? I want you to know I’m available to you.”
Move at the patient’s pace. We are all so task oriented. We want to chart and document and finish this and finish that. We are always rushing around. Take cues from the patient or client and don’t rush them.
Restore sense of control. Give people choices and stay away from acts or statements that are overly controlling and authoritative.
Do a lot of listening: What is the trauma victim saying to you? What are they not saying? How are they saying it?
Keep the patient whose experienced trauma informed: Tell them what is currently occurring, what will happen next in the process, Offer information and assistance.
Consider the person’s cultural context
Avoid making assumptions – just ask!
Recognize adaptive behaviors and coping mechanisms serve a purpose and should be explored not judged. Some adaptive behaviors could be chronically missing morning appointments? Coping mechanisms may include smoking or drug use.
Be familiar with available resources and give cards, pamphlets, phone numbers of websites to those you feel would benefit. If possible make a warm-handoff to an advocate or other resource.
Inform the patient you are available to help in the future but only if you are actually going to be available-never try to patronize or promise something you never intend to do.
These are a few quick tips to help you provide trauma-informed care and get someone who is suffering from the effects of trauma on the road to recovery. If you think about it, actually, a lot of this stuff is kind of common sense, right. I know it can hard to provide care and services time and again and to be smiley and happy and thoughtful. There never seems to be anytime with all the paper work, red tape and tasks we have to get done. Often times the places we work are hostile and difficult to work in. I know, I’ve worked in all types of settings from ER and Trauma rooms to acute psychiatric facilities. That’s why it’s so important to make sure they we make sure to take care of ourselves in order to provide the best care possible. In our next section we’ll talk about Helping ourselves to help others.

12. HELPING OURSELVES TO HELP OTHERS
One of the most important tasks you have to accomplish in helping a trauma victim is to manage your own trauma and stress. Vicarious Trauma, Secondary Traumatic Stress or Compassion Fatigue are terms often used to describe the trauma that is experienced by individuals who help others. We have a whole class dedicated to Compassion Fatigue that you need to watch but let’s just hit a few important points here. One of the things you need to do is to become aware of your own ACE scores and know your own risks. We already took the test together so you should now be familiar with your score.
A trauma-informed setting must account for Compassion Fatigue and develop trainings and systems to address issues of secondary trauma. Failure to address these problems and related problems involving institutional practices may further traumatize patients and harm you and/or your co-workers.
Compassion fatigue is a natural consequence of helping traumatized individuals. It’s often due to the empathy the “helper” feels from working with individuals who have suffered from trauma. Empathy is defined as the capacity to understand someone else’s state of mind. It’s putting ourselves in someone else’s shoes. This is good to do and a positive trait to have especially in the healthcare and human services industry. But if we don’t have clear boundaries and don’t take measures to protect ourselves and perform self-care then we can suffer from Compassion Fatigue. I suffered from compassion fatigue and boy was it bad. I saw all kinds of trauma both physical and emotional and I was empathetic but didn’t perform self care measures to help. Eventually over a relatively short amount of time I developed the classic signs and symptoms of Compassion Fatigue. It was almost career ending but I took some simple steps to combat it. One of the most important things you can do is to be aware about it. That’s right. Knowing is half the battle.
Here are few classic signs of compassion fatigue. They are: Irritability, Apathy, Loss of Motivation, Fatigue, Feeling Overwhelmed, Loss of interest in things you enjoy, Intrusive thoughts (especially about work). If you are having these symptoms please take the necessary steps to care for yourself so that you can be the best you for yourself, your family, friends and the people you take care of.
A few steps and tips you can perform to help you deal with Compassion Fatigue and to help you work with those who have been traumatized is to do the following: Maintain a work/life balance, Eat healthy, Exercise, Maintain a good support system, Don’t be afraid to feel emotions, Develop a plan to implement healthy behavior, Develop healthy boundaries, Do not feel afraid to ask for help, Use resources available or consult a counselor, therapist or some other professional. These are a few of the basics you can do to get you started on the path toward healing. Remember you have to take care of you. You make a huge difference in this world and we need you to be the awesome person we know you are so make sure you stay healthy and awesome!

13. WHAT DOES IT ALL MEAN?
Wow, we covered a lot of important stuff. Understanding trauma and its impact on lives and society as a whole is perhaps our generations new germ theory. Like hand washing people thought the idea of microscopic organisms causing disease and death was dumb and unsubstantiated. I think a lot the healthcare and human services industry take a similar view of trauma. So then it is up to us to share the information about this public health concern of trauma.
So, what does it all mean? What did we create this class and why did you take it?
We’ve already taken the ACE test together. Remember, ACEs are common and you probably all have at least an ACE score of 1. Some of you may have 2, 3 or even higher. Don’t be discouraged though by how many how your ACEs are because we all have the ability to adapt, resolve past traumatic events and start on a path to healing.
Some important aspects about the ACE study are the fact that the study’s participants were an average cross section of Americans. They weren’t poor, disenfranchised or living in areas typically known for violence. So this average sampling shows and suggests that Trauma and its related issues is something that affects all of us, not just one segment of society. This is a public health problem. The ACE study changed the landscape of our understanding of Trauma and its influence on public health problems such as depression, substance abuse, Cancer, heart disease, chronic lung disease and diabetes.
We’ve learned in this course that the body’s biology and physiology is really good at alarming us to danger but the system breaks down when there is prolonged and repeated events triggering us. Flight, fight, and freeze hormones are really helpful when being chased by a mean dog or when we need to stand up and fight someone or something off. Freezing can also help us remain undetected by a quote unquote predator. But in the presence of ongoing trauma, such as a father coming home every night from the bar and is physically abusive, the stress becomes toxic and can begin a cascade of events across the whole life span leading to problems in behavior, social problems, increasing the chances of risky behaviors and lifestyle choices along with changing the very DNA and cells of our bodies. The sad part is all of these circumstances, events, choices, and physiological changes can lead to an early death.
The impact of trauma goes beyond the traditional boundaries of our health and services systems. Society along with our healthcare and human services professions have tended to treat violence, abuse, neglect and other traumatic experiences as an outlier or sort of uncommon situation. We respond to these situations in a reactionary and emergency response manner by getting Child and Family Protective services, foster care and alternative schooling situations in place. But have we been getting it all wrong? No doubt these services are important and essential but are they just putting a band aid on a huge wound that needs to be looked at closer. A closer look needs to be made and setting up prevention and effective treatment utilizing trauma-informed care.
In this course we’ve learned that trauma is commonplace and we can no longer can we remain silos only thinking about how our specific profession will handle issues, diseases and health concerns and the traumatized. Now is the time to work together to breakdown the walls and work towards integration of the criminal justice system, educational system, healthcare, mental health, public health and corporate organizations and systems.
We must be a united front that shares resources and knowledge that will replace our fragmented approaches to victims of trauma. We must treat all individuals, especially those traumatized, with honor, care and compassion while understanding and providing solutions and support for emotional, mental and physiological problems cause by traumatic experiences.
This isn’t just a mental health workers problem or social workers problem. It isn’t just the ER staff problem or family and child welfare services. This is a team sport. The faster we learn to work together to treat and prevent trauma the faster we can move our society toward greater levels of health and wellness. Thank you so much for joining me for this class. It’s our hope that you take the information you learned and apply it to where ever you work. Remember, we have the awesome opportunity and responsibility to provide awesome care and do our job to make this world a better place. We’ll see you next time.

Writers and References

Writer(s)Donn Kropp, RN, MS

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Lessons

Introduction (Preview)

Length: 30 minutes

Trauma is difficult to understand. It can’t be viewed narrowly but must be understood broadly and take into account biological, psychological, interpersonal, community, and societal factors. In this lesson, we’ll…

Objectives

Length: 2 minutes

Emotional and psychological trauma isn’t as cut and dry as we once thought. In this lesson, we will highlight the objectives for this course.

What is Trauma

Length: 51 minutes

Several definitions of trauma exist. Trauma can be described as any event that overwhelms a person’s capacity to cope and has long-lasting impact. In this lesson, you will learn about…

The Biology of Trauma

Length: 48 minutes

Trauma affects our bodies and physiology in a number of ways. In this lesson, we will explore several systems of the body and uncover the effects of trauma.

Experiences and Responses to Trauma

Length: 39 minutes

One of the most important and significant ways to be Trauma-informed is to have an understanding of the signs and symptoms of trauma. In this lesson, we’ll explore the signs…

The ACE Study

Length: 44 minutes

ACE stands for Adverse Childhood Experiences. In this lesson, we’ll examine the ground-breaking ACE study and explore how adverse childhood traumatic experiences affect health later in life.

Trauma-Informed Care

Length: 31 minutes

In this lesson we’ll introduce you to the concept of Trauma-Informed Care. In healthcare and human services settings, emotional and psychological trauma often goes unnoticed, ignored, or unaddressed. Providing trauma-informed…

Implementation Domains

Length: 30 minutes

In this lesson, we’ll explore the 10 implementation domains of Trauma-Informed Care.

Responding to Trauma Disclosures

Length: 13 minutes

Caring, appropriate, and empathic responses to those who share their past traumatic experiences can be beneficial and healing to the victim. In this lesson, we’ll help you be supportive, encouraging,…

Quick Tips

Length: 15 minutes

In this lesson, we’ll condense and highlight the important points so that you can effectively implement Trauma-Informed Care in your practice.

Helping Ourselves

Length: 14 minutes

One of the most important tasks you have to accomplish in helping a trauma victim is to manage your own trauma and stress. In this lesson, we’ll explore vicarious trauma,…

What Does It All Mean

Length: 46 minutes

In this lesson we’ll review the concepts learned. Understanding trauma and its impact on lives and society as a whole is perhaps our generation’s new germ theory. It is up…