Workshop presented by Nancy J. Smyth, PhD, LCSW at NYS School Social Workers Association Annual Conference, Buffalo, NY 11/4/11

1. TRAUMA-INFORMED CARE
Nancy J. Smyth, PhD, LCSW
Professor & Dean
UB School of Social Work
NYS School Social Workers Association
Annual Conference
Buffalo, NY 11/4/11

2. Much of this content is from online workshop developed
by Professor Sue Green & myself on trauma-informed
care and creating trauma-informed organizations.

3. Agenda
• Mental Health System: Why This is
Needed: Case Example
• Trauma: Definition & Impact
• Trauma-Informed Care

4. http://www.theannainstitute.org/obi.html
ANNA CAROLINE JENNINGS
1960 - 1992

5. This is Anna at age one This is Anna years
and a half later – in a mental
institution
What happened?

6. Anna's Retraumatization In Mental
Health System
Jennings, A. (1994) On being invisible in the
mental health system. Journal of Behavioral
Health Services , 21(4), 374-387.
See http://www.theannainstitute.org/obi.html

7. Trauma Definitions
• DSM IV: Event involving actual or
threatened death or serious injury, or a
threat to physical integrity of self/others
(experienced/witnessed) (DSM-IV)
• Meichenbaum (1994): Event(s) so
extreme, severe, powerful, harmful, or
threatening they require extraordinary
coping efforts (experienced /witnessed)

8. Defining Trauma
McCann and Pearlman (1990)
Psychological trauma:
• is sudden, unexpected, or non-normative.
• Exceeds the individual’s perceived ability
to meet its demands
• Disrupts the individual’s frame of reference
and... psychological needs...

9. Consequences of Trauma
Increased:
– Fight, flight, freeze response
– Hypervigilance, arousal, paranoia
– Perceptual and information processing
distortions
– Pain tolerance
– Emotional blunting
– Aggression and irritability

10. Consequences of Trauma
Decreased:
– Memory processing and retrieval
– Reality testing
– Body and emotional awareness
– Immune response

11. Trauma Reactions
• Type I: Short-term, unexpected event
– Examples: One time rape, car accident, natural
disaster
– Likely to result in typical PTSD sx
• Type II: (Complex Trauma): Sustained,
repeated ordeal stressors
– Examples: ongoing physical/sexual abuse, combat
– More likely to result in long-standing characterological
& interpersonal problems, dissociation, substance
abuse

12. Prevalence of Trauma
• Study of 2nd yr. students in college found that at
least 84% had experienced at least one major
trauma
(Vrana & Lauterbach,1994)
• “Some people never experience the most
serious levels of trauma in their lifetimes,
however, the majority of people experience at
least one traumatic stressor….”
(Resick, 2001)

13. Prevalence of Trauma
At Risk Populations
• Mental Health Tx: 40%-60% childhood
victimization
• Substance Abuse Tx:
– 60%-70% women child victimization
– 90% women domestic violence
– 60% men physical assault victims
– 33% men child sexual abuse

14. Youth Rates
• National Study of 12-17 yr. olds (Kirkpatrick &
Saunders):
– 8% sexual assault
– 17% physical assault
– 39% witnessing violence
• Western North Carolina Study (Copeland et al.,
2007). Instead of full blown PTSD, children
experienced school problems, emotional difficulties,
and physical problems
– 20% of children exposed to 1 trauma
– 50% of children exposed to >1

15. Impact on Cognitions
People will hurt me
I’m helpless to prevent bad things from
happening
I’m defective
I don’t matter
I’m helpless
I’m worthless
I can’t trust anyone
You will hurt me

16. Adverse Childhood Experiences
(ACE) Study
• Collaboration between Kaiser Permanente of San Diego and
Centers for Disease Control and Prevention (CDC).
• Initial phase conducted from 1995-1997 in two waves.
• Participants were given a standardized physical exam and
completed a confidential survey on child maltreatment, family
dysfunction, current health status and behaviors.
• Unique opportunity to examine the relationships between a
broad range of adverse childhood experiences (ACEs) and a
wide range of health and social consequences in adulthood.
(Adapted from http://www.cdc.gov/ace/prevalence.htm)

17. Adverse Childhood Experiences
(ACE) Study
• Middle class adults (N = 17,337) 54% female, 46% male.
• Race/Ethnicity: 75% White; 11% Hispanic/Latino; 7%
Asian/Pacific Islander; 5% African-American; 2% other.
• Age (years): 5% 19-29; 10% 30-39; 19% 40-49; 20% 50-59;
46% 60 and over (mean age = 56).
• Education: 39% college graduate or higher; 36% some
college;
18% high school graduate; 7% did not graduate from high
school.
(Adapted from http://www.cdc.gov/ace/prevalence.htm)

18. Adverse Childhood
Experiences (ACEs)
Growing up experiencing any of the following conditions
in their household prior to age 18:
1. Recurrent physical abuse
2. Recurrent emotional abuse
3. Contact sexual abuse
4. An alcohol and/or drug abuser in the household
5. An incarcerated household member
6. Someone in the household who is chronically depressed,
mentally ill, institutionalized, or suicidal
7. Mother is treated violently
8. Parents separated or divorced
9. Emotional neglect
10. Physical neglect

19. ACEs increase the adult risk
for many health problems
(Felitti et al., 1998)
• Heart disease • Diabetes
• Chronic lung • Stroke
disease • Skeletal fractures
• Liver disease • Poor self-rated
health
• Cancer
• Other risks for the
• Physical inactivity leading causes of
and obesity death

20. ACEs increase the risk
for many other social problems
(From www.cdc.gov/ace)
• Intimate partner violence
• Multiple sexual partners
• Unintended pregnancies
• Early initiation of sexual activity
• Adolescent pregnancy
• Sexually transmitted diseases
(STDs)
• Fetal death

21. Adverse Childhood Experiences
(ACE) Study
• ACEs very common:
– 2/3 of the sample had 1+
– > 1 in 10 had 5 +
• ACEs are highly interrelated: tend to occur in clusters rather than as
single experiences; the occurrence of one should prompt a search
for others.
• Interrelatedness suggests examining tthe effects of a single ACE on
health and well-being is misguided.
• Cumulative impact of multiple exposures can be captured in an
“ACE Score.”
• Consequently, an integrated approach is needed to intervene early
with children growing up in households where ACEs are present.
(Adapted from Anda, 2007)

22. The Impact of Trauma on the
Brain

23. Information Processing & The
Brain
Left Hemisphere Right Hemisphere
• Language • Evaluates emotional
Production sense data
• Stores Narrative • Integrates Sense
Data Data
• Cognitive Analysis • Non-
• Declarative/Explicit declarative/Implicit

24. Traumatic Memory
Fragmentation
• The Compartmentalization of Experience:
elements of a trauma are not integrated
into a whole narrative or sense of self.
• BASK Model of Memory (Braun)
– Behavior: What we do
– Affect: What we feel
– Sensation: What we perceive in our bodies
– Knowledge: What we think and remember

25. Normal vs. Traumatic Memory
Event Event
B A
BASK K
S

26. “THE WALL”

27. “THE WALL”
(Greenwald, 2005)
The “Trauma Wall”
– Sometimes upsetting experiences do not get
processed; sometimes its just too much to
face
– Maybe the event was too upsetting and
overwhelming
– Many people try to push the unsettling
experience ‘behind the wall’: it is a
representation of a temporary solution

28. “THE WALL”
• Problems with “The Wall”
– Memory stays fresh, keeps its power
– Conflict between cognition and emotion: the head and
the heart
– Memories leak out: memory is triggered or activated
by something thematically related
– Memories stockpiled behind the wall become a ‘sore
spot’
(Greenwald,2005)

29. Emotional Hijacking
(Goleman; Nijenhuis)
Emotional “Pocket”
Apparently Normal (Holds Traumatic
Self Memory)
Consciousness

30. Systems of Care
Messages/Actions confirming traumogenic
perceptions of self & others:
No progress expected
“you’re defective and hopeless”
Disregarding valid needs/requests
“you don’t matter”
Over-emphasis on Compliance vs. Collaboration
“you are powerless”

31. What is “Retraumatization”?
 A situation, attitude, interaction, or environment
that replicates the events or dynamics of
the original trauma and triggers the
overwhelming feelings and reactions associated
with them
 Can be obvious - or not so obvious
 Is usually unintentional
 Is always hurtful - exacerbating
the very symptoms that brought
the person into services

32. Impacts of Retraumatization on
Consumers
 Decrease or loss of trust
 Higher rates of self-injury
 Significantly less willingness to engage in any treatment
 Increase of intrusive memories, nightmares and
flashbacks
 Reexperiencing of symptoms and emotions from
previous trauma – when extreme may take on
delusional intensity
 Increase in chronicity of stress with greater risk for
psychiatric morbidity, e.g. PTSD, chronic depression

33. Trauma-Informed Care
Will avoid inadvertent retraumatization and
will facilitate consumer participation in
treatment
(Harris & Fallot, 2001)

34. Trauma-Informed Care (TIC)
We stop asking:
“What is wrong with this person?”
and begin asking….
“What has happened to this person?”

35. Trauma-Informed Care
May not be specifically designed to treat the actual
trauma, but:
– Are informed about
– Sensitive to trauma related issues present in
survivors and communities
– May treat with trauma-specific treatments
(Jennings, 2004)

36. Trauma-Informed Care
Provides services which allow clients to
• feel safe
• be accepted
• be understood
by everyone who may come in contact
with the client

37. 5 Guiding Principles of TIC
1. Safety
2.
5.
Trustworthiness
Empowerment
4. Collaboration 3. Choice

38. 5 Guiding Principles of TIC
1. Safety
includes where services are offered; time of day that
services are offered; security personnel available,
open doors or locked and the affect that each has on
2.
5.
consumers; waiting room appearance; are all staff
Trustworthiness
Empowerment
members attentive to signs of consumer discomfort
and do they recognize these signs in a trauma
informed way?
(Fallot and Harris, 2006)
4. Collaboration 3. Choice

39. 5 Guiding Principles of TIC
1. Safety
includes providing clear information about what will be done,
2.
5. by whom, when, why and under what circumstances;
Trustworthiness
Empowerment
respectful and professional boundaries; is unnecessary
consumer disappointment avoided; is informed consent taken
seriously on a consistent basis?
(Fallot and Harris, 2006)
4. Collaboration 3. Choice

40. 5 Guiding Principles of TIC
1. Safety
2.
5.
includes how much choice consumers Trustworthiness
Empowerment
have over the services they receive (such
as time of day, gender preferences for
service providers, etc.); are consumers
provided a clear and appropriate message
about their rights and responsibilities?
4. Collaboration 3. Choice
(Fallot and Harris, 2006)

41. 5 Guiding Principles of TIC
1. Safety
2.
5.
Trustworthiness
Empowerment consumers a significant role in planning
includes giving
and evaluating services; consumer preference is given in
areas of service planning, goal setting, and developing
treatment priorities; cultivating an atmosphere of doing
“with” rather than doing “to” or “for”; conveying the
message that the consumer is the expert in their own life?
(Fallot and Harris, 2006)
4. Collaboration 3. Choice

42. 5 Guiding Principles of TIC
1. Safety
2.
5.
Trustworthiness
Empowerment
includes recognizing consumer strengths and skills;
building a realistic sense of hope for the client’s future;
provide an atmosphere that allows consumers to feel
validated and affirmed with each and every contact at the
agency
4. Collaboration 3. Choice

43. Culture Change in Human
Service Programs
1. Initial Planning
2. A kickoff Training Event
3. Short-term follow-up
4. Longer-term follow up
(Creating Cultures of Trauma-Informed Care (CCTIC): A Self-Assessment and Planning Protocol,
2009)

44. Culture Change in Human
Service Programs
Service-Level Changes:
• Program Procedure and Settings
• Formal Service Policies
• Trauma Screening, Assessment, Service
Planning
(Creating Cultures of Trauma-Informed Care (CCTIC): A Self-Assessment and Planning Protocol,
2009)

45. Culture Change in Human
Service Programs
Systems-level/Administrative Changes
• Program-Wide Trauma Informed Services
• Staff Trauma Training and Education
• Human Resources Practices
(Creating Cultures of Trauma-Informed Care (CCTIC): A Self-Assessment and Planning Protocol,
2009)

46. TIC in Schools
• What Practices/Processes Are Likely
Triggers?
• What Would TIC look like in a School?

47. Although the world is very full of
suffering, it is also full of the
overcoming of it.
– Helen Keller

48. Resources
• Podcasts (free audio recordings) on UBSSW website:
http://www.socialwork.buffalo.edu/podcast/ and sort on
categories, then trauma
• National Child Traumatic Stress Network:
http://www.nctsn.org/
• National Center for Trauma-Informed Care;
http://www.samhsa.gov/nctic/
• UBSSW Continuing Education:
http://www.socialwork.buffalo.edu/conted/

49. Guiding Principles of Trauma-Informed Care
(Fallot & Harris)
SAFETY: includes where services are offered; time of day that services are offered; security personnel available, open doors or locked and the
affect that each has on consumers; waiting room appearance; are all staff members attentive to signs of consumer discomfort and do they
recognize these signs in a trauma
TRUSTWORTHINESS: includes providing clear information about what will be done, by whom, when, why and under what circumstances;
respectful and professional boundaries; is unnecessary consumer disappointment avoided; is informed consent taken seriously on a consistent
basis?
CHOICE: includes how much choice consumers have over the services they receive (such as time of day, gender preferences for service
providers, etc.); are consumers provided a clear and appropriate message about their rights and responsibilities?
COLLABORATION: includes giving consumers a significant role in planning and evaluating services; consumer preference is given in areas of
service planning, goal setting, and developing treatment priorities; cultivating an atmosphere of doing “with” rather than doing “to” or “for”;
conveying the message that the consumer is the expert in their own life
EMPOWERMENT: includes recognizing consumer strengths and skills; building a realistic sense of hope for the client’s future; provide an
atmosphere that allows consumers to feel validated and affirmed with each and every contact at the agency
Nancy J. Smyth, PhD, LCSW, University at Buffalo School of Social Work at NYS School Social Workers Association Annual Conference, Buffalo, NY 11/4/11