Good morning, my name is Stephanie Stilwell, and we are addressing trauma-informed care practices in substance use disorder treatment today. And I'm going to skip through some of these initial slides, as they're all about the Opioid Response Network, and you all should have heard and learned about us by now. So again, today we're going to be talking about something called trauma-informed care practices. So when we think about treating people with substance use disorders, it's important to remember that a lot of the people who suffer or struggle with addiction or substance use disorders have experienced some type of significant trauma in their lives. And so trauma-informed care recognizes that this is the reality and works to change how we approach helping people in treatment. So instead of asking people, hey, what's wrong with you, we're going to shift that and ask what has happened to you. So the simple shift in perspective can really make a huge difference in helping us create a safer and more supportive environment for people to recover and heal. So today we're going to really dive into what trauma-informed care looks like, both in practice and how it can help us better connect with and support individuals that we serve. So this quote says, trauma-informed care is based on an understanding that recovery is possible and achievable for everyone, regardless of how vulnerable they may appear. So in order to understand what trauma-informed care practices, we have to really kind of take a step back and define what trauma is in itself. So trauma can be defined as a event, a series of events or set of circumstances that's experienced by an individual that's physically, emotionally harmful or life-threatening and that has significant lasting adverse effects on the individual's functioning, mental health, physical health, physical, emotional, or even spiritual well-being. And of course, there's a lot of different types of trauma and levels of trauma. So we're going to kind of talk about the different types of trauma that people can experience. So if we're looking at this photo here, we'll see in the smallest circle in the middle talks about something called individual trauma. So this is trauma that impacts really only that one person. So it could be something like somebody has gone through a significant illness or injury that was really impactful in their life. So it's something that happens to just one person. And then we're moving up into the family trauma. This is something that impacts multiple people within one particular family. And then beyond that, we're going to bring us into group trauma, which is some sort of trauma or event, something that happened to a particular group. So let's think of this more as like people in the military or first responders. That's something, a shared experience between that particular group of people or nursing, healthcare staff, things like that. And then we're going to move into some types of community trauma. So these are, this is some type of trauma that impacts a few people, but has kind of a bigger structural or social traumatic consequence. So there's, of course, cultural trauma. So this is a type of community trauma that happens when a group that shares a culture or a specific identity experiences an event that creates lasting effects on that group. So a good example of this is some of those historical traumas and racial trauma as well. This is, these are all types of community trauma. And then at the top, we have mass trauma. So this is trauma that affects a large number of people. So a good recent example of a mass trauma is the COVID-19 pandemic. That is something that all of us experienced at the same time. So that's a mass trauma. And then I also want to point out that within the individual trauma, there's also different types of traumas as well. So there's interpersonal trauma, whoops, sorry, interpersonal trauma, developmental trauma. And then there's something called systems-oriented trauma. This is, well, we'll dive into systems trauma in just a little bit. So some other examples of trauma, if you want to think of things as trauma as a big T trauma and trauma in little t. This doesn't necessarily mean the big T is more important or impactful than the little t, but it's just in the way we're thinking of things. So some of the big T traumas include things like war, disasters, childhood, SA, physical abuse, car accidents, victim, crime, victimization, or witnessing DV or experiencing DV or some sort of death. And then examples of little t include things like emotional abuse, neglect, failure experiences, phobia-related experiences, some other types of losses, stress that's at work or school, bullying, and DV as well can be in this depending on the severity. So again, just because they're labeled as big T or little t doesn't mean that one has more or less of an impact on somebody's life than the other. So when we're in the clinic and we're working with a patient, if we start to notice some different behaviors coming out, we can start to think of it as possibly maybe we're seeing some behavior based on some trauma that they've had experienced in the past. So what trauma could look like in the clinic setting might look like if they're so emotionally dysregulated, they're angry, they're frustrated, their just emotions are very big, or maybe they're blunted or they're worrying, panics, just some sort of emotional change. Similarly, folks might be more impulsive, have a little bit more aggression, be hypervigilant, or maybe they're avoidant. They might have trouble sitting still or staying on task. They might have either low energy or extreme excessive energy, they might have trouble sleeping or engaging in high risk behaviors. And continuing on what trauma could look like is cognitively, this could look like easily distracted, not very focused, or somebody who has really a hard time setting goals, knowing a series of tasks or steps to achieve their goals, or even somebody who might be struggling to find the words to share something. And when it comes to like relationship building, if you're struggling with building a relationship with a client, that could also be some trauma behavior, trauma impacts as well. So relationally, they might not share enough with you, or they conversely could overshare. They don't want to get too close to people, they could be avoiding or ghosting you or the clinic staff, extra sensitive and or having a fear of rejection. So again, these are more examples of impacts that trauma could have on individuals and especially things that we can observe in other people. Emotionally, again, there's that dysregulation of emotions, depression, anxiety, numbness. They could, again, have PTSD. Behavioral, this is where we might see people engaging in substance use or having substance use disorders, self-destructive behaviors, avoiding people, situations, places that could include avoiding clinic visits. Physical, a lot of people have physical components related to trauma. So this could be headaches, high blood pressure, fatigue, or extra tension, insomnia, related to hyperarousal. We have developmental impact, again, this is really important when we're working with youth. So children, trauma can impact changes in brain development. We talked about cognitive impairment. Sometimes their short-term memory might be decreased, unable to focus. When we, again, we talked about interpersonal. So this is that relationship building. They might struggle with building relationships with us or with their family or their community or friends or have trouble with trust. And then we also see an impact on their spiritual well-being as well. So depression and loneliness can also lead to those feelings of abandonment and or having loss of faith, whatever that looks like to them. And then that could create less appreciation for the life that they have or struggling with not having a purpose of some kind. So when we talk about trauma-informed care practices in healthcare, we need to think of it as more than just a set of practices. It's not just the step that we take here or this, you know, box we check over here. It's really and it's a transformative approach that really recognizes that deep impact that trauma has on people. So it emphasizes the importance of creating an environment like physical environment that creates safety for both providers and the trauma survivors where they can feel safe and empowered and supported in their treatment. Trauma-informed approaches really grounded in understanding and responding to trauma in ways that prioritize physical, psychological, and emotional safety for everybody. So the goal is to really help individuals rebuild a sense of control and environment and control and empowerment in their lives. And it's also important trauma-informed organizations and services are designed to be aware of all the different triggers and vulnerabilities that people might who've experienced trauma might face. So it's really important for us to kind of think steps ahead to make sure we are not inadvertently like re-traumatizing somebody. So that's by fully integrating knowledge about trauma into like all the different aspects of the care that we provide, we can create a more supportive and healing environment for everybody. So traumatic experiences directly impact an individual's overall health and wellbeing. That really does also impact how they engage with us and they receive their services and their care. So when someone discloses trauma, whether it's in the past or it's currently happening, it's really important for us to understand and respond, understand how to respond and be sensitive to that information. So in recognizing the impact of trauma allows us to improve health outcomes and manage risks more effectively for these folks. Trauma-related symptoms and behaviors often develop as a way for people to cope with some of those overwhelming experiences. So by us understanding that, it helps us address some of those underlying issues more effectively. So let's see, where was my next point here? So there's four R's in trauma-informed care. The first is realization. So this refers to the understanding and the acknowledgment of the widespread impact of trauma and its potential manifestations. The second R is recognition. This involves recognizing the signs and symptoms of trauma in individuals, families, and even communities. Response. This emphasizes the importance of integrating knowledge about trauma into policies, procedures, practices, to effectively respond to the needs of these trauma survivors. And then number four is resilience. So this focuses on promoting resilience among individuals who experience trauma, which fosters a supportive environment that helps them recover and thrive. So realization, recognition, response, and resilience. So as we work to support individuals who've experienced trauma, it's important, again, to recognize that certain practices within our services can actually re-traumatize the people that we are actually trying to help. So for example, a lack of privacy or even an unwanted physical touch, you know, just tapping somebody on the shoulder or touching them at all, that could cause, that could trigger people who've had trauma in their lives. And even though it's well-intended, it can, you know, maybe bring up some distressing memories that somebody has experienced. So there's other types of traumatization, staff bias, potentially like us having our own biases, including race, ethnicity, gender, sexual identity, class, and or, you know, if we talk about stigma around substance use disorder specifically, there's, you know, we have to really check in on that. We sometimes ask questions that are actually really important for us to know the answer to, but it might be triggering for people. So thinking about things is having only one right answer or one right way of doing something. Approaching a patient from the lens of like, we're the expert and they're the recipient versus, okay, we're a team working together to help them. So kind of having that hierarchy, patient-client, yeah. And then sometimes even just like looking at our policies and procedures. So having policies and procedures that are really rigid and strict, like having, if somebody no-shows or is 15 minutes late, that might be really stressful or hard for somebody to actually make happen, which can cause more trauma and trigger them to actually make it more difficult for them to get to their appointments on time. So why a trauma-informed approach matters for both clients and providers. So implementing a trauma-informed care approach benefits not just individuals who are receiving that care, but also the providers who are delivering it. So that would be us. So when our clients receive care, that acknowledges in response to their trauma, they receive better, more effective services. And for staff, understanding and applying more trauma-informed care practices helps us cope more effectively with the emotional demands of our job, which helps us to be more resilient in our work and our home life as well. So this approach contributes to better staff retention, reduces turnover, because it creates a better environment and some more supportive environment for us to work in. So additionally, by reducing the levels of vicarious trauma the staff might experience, a trauma-informed care approach promotes both self-care and just an overall workforce wellness. So this ensures that both clients and providers are thriving. So one, I've heard individual trauma-informed care approach is also individual self-care and organizational workforce wellness. So when we, we also wanna think about how culture impacts our work. We talked about trauma and the different levels of trauma. So there's also, we wanna make sure we're addressing the cultural traumas that might, our clients might experience as well. Culture, of course, plays a crucial role in shaping a person's life, regardless of whether they're indigenous or from another culture, culture is important. This helps them really perceive and make sense of kind of their life experiences. And so when we're looking at trauma-informed care, it's important to acknowledge and address cultural influences, especially when we're working with survivors of trauma. So this involves recognizing and confronting our own racial or cultural biases, which we discussed earlier, and being open to honest conversations with ourselves. Historical trauma, especially among American Indians or native Alaska natives, combined with ongoing challenges that are still existing, like racism and poverty, these can really continue to have devastating impacts on people. So it's really important to make sure we're addressing culture so we can better understand and address the unique needs of the people that we're serving to make sure they're getting more equitable and effective care. So I have a story, so it's not my story, but it's a story that happened. So this is about Tommy, who is 24, and he's from South Dakota. During active combat, Tommy would sometimes see a light around him that deflected enemy bullets away. Tommy said that other times during combat, he would hear his Lakota ancestors speaking to him and telling him not to worry and that he was gonna live and be free from injuries or death. He added that his grandmother's voice told him that if he did get shot to sing his death song, and so the ancestral spirits would be with him to join him and provide care and assistance to him as he journeys to the other world. So he continued by saying that by keeping to the traditional ways and abstaining from alcohol and working to help others who had gone through war as well, he could live with harmony and balance in his life. And he explained this as this is the Lakota way. Now, he's talking to a provider and somebody had told him something along the way. And after he tells the story with you, he says, do you think I'm delusional or psychotic? Because as he had been telling this story to somebody that was not familiar with his culture, instead of asking questions or understanding that this is part of his culture, they're hearing that he's talking to the voices of people who have died in the past or that he's seen things. And so this really is an example of somebody that was not familiar and didn't pay attention to cultural context and really caused some trauma and impacted some of his wellbeing, both emotionally and spiritually. So it's just a really important story to remember about why culture is such an important piece. So as healthcare providers, now we realize we are working with trauma survivors that our patients have all experienced something. And while it might not be 100% all the time, like we can't avoid people re-experiencing trauma, but we can do our best to offer tools that help clients manage the stress and distress while they're in our office. And help them to find tools that can ground them during those triggering moments. And sometimes it's some of the simplest things that we can do to provide that service to them. So one really easy and effective way to support your patients is just by creating a coping or soothing kit. That this can be something that is readily available right in your office or even in the waiting room or any areas in the clinic that you feel like somebody could encounter some stress or re-traumatization of some kind. So these kits can include things like sweet and sour candy, or these help us to tap back into our senses in the present moment. So there's other things like stress balls, things that we can squeeze, touch, smell, listen to, just really engaging in our senses to re-ground us in. So by having kits available, you're providing your patients with some immediate and practical tools that can help them really feel safer in that moment. And maybe something that you can send home with them as well. Another example, this one is another example of somebody being, you know, who had experienced re-traumatization in the hospital setting. So it's about a woman named Brenda, she's 20. In the emergency department of a busy hospital, they have a policy that requires nursing staff to confiscate the clothes of people who are admitted for self-injury or suicidal feelings. So the policy was developed to protect patients by ensuring that they don't bring in anything that can cause harm. Brenda is a woman who's experienced some sexual assault at some point in her life and never reported it. She's admitted to the hospital for self-injury and is asked to remove her clothing, but she refuses. And because she refuses, Brenda is held down by a male security guard while a nurse is removing her clothing. Her heart's pumping, she can't think clearly, her breathing is getting shallow, she's entering her fight, flight, freeze response and the ER staff ends up giving her chemical and physical restraints to get her to calm down. This is a scenario that I feel we could have a lot of discussion about like what they did that was not trauma-informed care. So I just want you to really think about like, what are some of the better ways that we could have handled this situation or we, they could have handled the situation? Because this is not quite the most appropriate or trauma-informed way to handle this situation. So I want you to really contemplate and think how you would make different choices in this or what policies you could do to change within your organization to address this. Just some other examples of patients to think about. There's, let's see, you're meeting with a woman named Sarah to complete paperwork for services that she's requested through your organization. She's talking or she's wrestling through her bag while you're talking, looking outside, checking her phone, she's just really distracted. What do you think is really happening? What is she experiencing? Now that you have an understanding of some trauma responses behaviorally, what do you think is really going on and how can you help her in that situation? Another is Andre. He agrees to go to mental health counseling but no shows for his intake. During follow-up, he again, says he's really interested in going, makes an appointment, but he no shows again. So what do you think is really going on? And again, what can you do to help? And now we're gonna kind of switch gears a little bit to talk more about how to integrate a trauma-informed approach in your organization. So building a culture of trauma-informed care goes, again, beyond just implementing a new service or checking a new box in your charting system. It requires really an entire comprehensive shift that touches all the different levels and aspects of your organization. So this culture shift really involves all the program activities, settings, relationships, and just the overall atmosphere of your organization. So it's important that every group, from administration and supervisors to direct service staff, support staff, janitorial staff, front desk staff, and the clients themselves play a role in the transformation. Making trauma-informed care a part of your just daily routine is really meaning, it really means that you're adopting a new way of thinking and acting that prioritize safety, trust, and healing in the work that you're doing. So again, it's not a one-time event. It's a process that is a continuous assessment on looking at your processes, looking at your policies and your practices and your staff and your training and everything that it takes to really kind of change this entire culture of how you do the work that you're doing. Ultimately, this again, is going to lead to the most supportive and effective environment for both staff and individuals that you're serving. Again, trauma-informed care makes such an important difference in the quality of care that we're providing. So again, it improves workforce wellness by fostering that sense of confidence, satisfaction among staff. It reduces burnout and stress, creates a more positive environment. This approach, again, helps to create more integrated care among the different departments within your organization. It helps to increase the engagement that the client has in their services that they've received in your organization, reduces no-shows, offers, or helps to reduce the number of emergency appointments or emergency room visits by the clients. So just ultimately, again, leads to higher satisfaction with care and better services provided. And this slide just really illustrates the concept of something called the parallel process, which is where the experience of a client, staff, and the organization are completely interconnected and often mirror each other. So when a client feels unsafe, overwhelmed, or hopeless, it's not uncommon for staff to also experience some of those similar emotions leading to helplessness, frustration, or demoralization. So understanding the interconnectedness between client, staff, and organization is really important so that we can help to, as we increase or implement effective trauma-informed care practices. Because, yeah, if we are looking at clients who feel unsafe, the staff often feels unsafe, the organization itself is unsafe. And in creating a trauma-informed organization, again, this is just reiterating the importance of the comprehensive approach. And that really impacts all aspects of the organization's operations. So trauma-informed organizations provide that calm, safe, secure environment where supportive care is priority, ensure a system-wide understanding of trauma, recognizing its prevalence, impact, and the importance of trauma-informed care. Again, cultural competence is crucial. We also wanna ensure that consumer voice, client voice, choice, and self-advocacy is at the forefront. Recovery, consumer-driven, and trauma-specific services are offered. And then, again, this really leads to some of those more helpful, healing, and honest, trusting relationships within the organization. So there's a lot of resources available for folks to learn how to implement trauma-informed practices in your workplace. So this is another, an example from, actually from SAMHSA, you can find it online. It'll kind of help you walk through all the different steps of how to create a trauma-informed workplace. And again, this is just kind of that process that I talked about. It's not just a one and done. This is the roadmap to trauma-informed care. So it starts, again, at this kind of where we are today. We're at the foundational readiness. We're looking at understanding where our organization is at, what, where, how ready are we to implement a trauma-informed care approach in our facility. And then once we get to a certain point, then we're ready to actually implement. But this implementation doesn't look like one and done. Again, it's a circle. So we're going to continue to assess and reassess how we're doing, what we can change, what we can do better, and just keep that moving forward. And again, this is just another food for thought. So bringing it all together. So if we were together today, I would encourage us to come together, but maybe this is something that we can, you all can do on your own time. But think about the importance of incorporating trauma-informed care in your organization. What are the things that your organization is currently doing well? What are some areas that you could improve? And as, I guess, both organization, but also an individual. All right, and that is what I have for you today. Again, if you have any questions, feel free to reach out. And this is just a short survey that you can do that shares information, or gives that you can provide feedback on today's presentation. Thank you.

trauma-informed care

substance use disorders

emotional safety

cultural influences

organizational transformation

client engagement

healing environment