So thank you everyone for joining us. My name is Emily Mossberg and I am Salthi Kamira's counterpart on the ORN's Indigenous Communities Response Team for the Northwest region. And I know you all are familiar with the Opioid Response Network, but as a reminder, the ORN and today's presentation is funded by a grant through SAMHSA. This funding enables the ORN to provide free training and consultation around opioid and stimulant use disorders. And today we are going to be talking about trauma-informed care as it relates to substance use disorder. Please note this session is being recorded and CE credit is available for attending. Salthi will be sending out the recording and CE instructions within about two weeks. All right, our presenter for today who you all met last week is ORN Consultant, Stephanie Stilwell. Stephanie is a registered nurse with a diverse background in the healthcare industry. She's also a member of Lac La Croix First Nation in Ontario, Canada. Thank you, Stephanie, for being here with us. I will now pass it over to you. You can go ahead and share your screen as well. Thanks, Emily. I'm just wanting to open it up in case anybody from your team wants to start with any blessing or anything I know last week we did. So I just want to open space in case somebody wants to do that. Otherwise, I'm happy to just jump in. So, okay, since there is no volunteers for that, that's great. I will go ahead. I'm gonna share my screen. I am on public wifi, so I'm gonna stop my video and hope that we have less tech issues than we had last week. So let's see. Here we go. Okay. Emily, are you seeing my presenting screen? Great, awesome. All right, turning off my video. And hello again. Yes, it's nice to be here with you all. Again, today we're gonna dive into trauma-informed practices as it relates to substance use disorder treatment. So as we go along, there we go. I'm gonna skip through some of the slides because Emily went through most of this for the ORN. But for today's presentation, again, we're gonna talk about and understand the principles of trauma-informed care and its relevance in the healthcare setting, specifically when it comes to substance use disorder treatment. We're gonna identify strategies to implement trauma-informed practices in clinical interactions. We'll have two case studies that we're gonna talk about and then how we can apply trauma-informed practices and approaches in our clinic settings. So I really like just starting with this quote, trauma-informed care is based on an understanding that recovery is possible and achievable for everyone, regardless of how vulnerable they may appear. So it's a very hopeful approach. So before we really dive into what is trauma-informed care and what is a trauma-informed approach, we're gonna spend a little bit of time discussing trauma in general. We're gonna talk about how to recognize when somebody is experiencing trauma and may be experiencing a trauma response, how we can recognize that and what we can do as providers to help. So, first I really wanna dive into what is trauma so trauma is essentially an event or a series of events or even a set of circumstances that is experienced by a person as either a physical or emotionally harmful or life-threatening experience that does have some lasting adverse effects on that individual and that can impact their functioning on their mental health, their physical health, their social, emotional, or even their spiritual wellbeing. So there's a lot of different types of trauma and different levels of trauma. So as we go through this, we'll start with the bottom here and talk a little bit about this individual trauma. This is individual trauma that typically affects just one person. So this could be something like an injury, an illness, something that is very specific to an individual. Beyond that, we have family trauma. This is something that some type of trauma or event that happens that affects multiple people within a particular family. So this could be, let's say if a family has a divorce or a fire in their home or something where it's very specific to that family in particular. And we move forward into group trauma. This is some sort of event or trauma that impacts a particular group. So you see this a lot in people who are in the military or first responders, people in the LGBTQ community. So it's something that occurs and impacts just a specific group. We also have community trauma and there's multiple kind of subcategories under community trauma. So community trauma is something that really does impact few people, but within a specific structural social kind of structure. So we have cultural trauma. This is something that typically impacts a group of people that share a cultural or identity of some kind. And they experience some sort of event that can cause lasting effects on that group's consciousness. Racial trauma. This is specifically an event or some sort of trauma could be hate, hate crime of some kind or threatened harm to an individual or a group of people based specifically on their race. And then something we'll kind of talk a little bit more today about is historical or generational trauma. This is like some widespread trauma that affects an entire culture and influences future generations even beyond those people who experienced it directly. So this is like in relation to generational historical trauma. This refers to, or this has something called epigenetics which refers to how the experience of traumatic experiences in an individual can actually cause gene expressions to be passed down into subsequent generations. So which potentially can affect the future stress responses and health outcomes of generations beyond. So, that's not just the people who have experienced something but if your great grandmother lived through something she passed that down potentially to her children who passed it down and that continues to move to go on. So, and then we have mass trauma. This is something that impacts a really large number of people. So a very relevant example of mass trauma is what we all just went through was the COVID-19 pandemic. So that is an example of a trauma experience that we all shared together on some level. So when it comes to trauma, one way of thinking of the different types of trauma is looking at big T's and the little t's. Now, when I go into explain them, I want you to realize that just because a person may have experienced a big T, that doesn't necessarily mean it's more traumatic to that person than a person who might experience a little T or vice versa. Every person's experience and response to trauma is extremely unique. And so that person's protective factors that they have in their lives can really help mitigate and decrease some of the negative impacts from trauma. Some of the examples of like the big T, the big traumas in people's lives are war, disasters, natural disasters, having experienced childhood sexual abuse or physical abuse, being in a car accident or being a victim of a crime, witnessing death or experiencing domestic violence. And some of the little t's are things like emotional abuse, neglect, failure, experiences, having some phobia, losses of any kind, just kind of an ongoing stress at work or school, experiencing bullying. And of course, domestic violence can be on that side as well. But again, it depends on like the person's ability to, you know, like what their protective factors that they have in their lives do. What are their, who do they have that can help support them through certain things? What are, you know, the protective, the things that can help them best cope with these experience of trauma? So somebody who has a lot of protective factors can go through a really big T and not experience it as negatively as someone who experiences a little t. And, you know, when it comes to how we're gonna talk, like think about trauma and incorporate it into the work that we're doing, it's really important to realize that we don't know a person's past experience. Sometimes we have clients and patients that tell us what their traumas are, what they've experienced, but sometimes we really don't know. And so it's really hard for us to understand why people might act a certain way when they're in the clinic. So as providers, it's really important for us to be able to recognize the signs of trauma and trauma responses and how it can present in the clinic so we can then like really actually help regulate them. So you might see a patient that comes into the clinic and they're extremely just dysregulated. Their emotions are all over the place. They're angry or frustrated. They're very short maybe, or they're kind of in a panic or worrying or feeling a lot of shame. And you might see behaviors that look like they're impulsive, they're making really impulsive decisions. They're kind of aggressive, they're hypervigilant or maybe they're avoiding people, avoiding you. They might have a lot of difficulty sitting still or staying on task. They might talk about some of the high-risk activities they're involved in, or sometimes they might come in the office and they're extremely sluggish or they're super hyperactive. These are all some... Trauma... Look like in patients. Stephanie, you're cutting out a little bit. Just so you know. The clinic. It may have been my internet, nevermind. Or they have a lot of trouble... Thanks for your patient, everyone. Can you hear me now? Yes. Okay. Awesome. Sorry about that. Hopefully, there's no more interruptions. We also might see people as extremely distracted, like they're not able to focus or they might have trouble following through with anything especially in regards to treatment or they just have difficulty initiating a task. Sometimes if we're talking to somebody and they really are unable to speak, sometimes it's just they have this reduced access to language. When it comes to creating a relationship with patients and creating that trust, sometimes there's a real struggle with that. Sometimes our patients might share too much or they are really hesitant to share anything. They have a lot of trust issues or they don't want to get close to people. They could be extra sensitive and or fear of being rejected or disliked. Also, I really want to point out, like in addition to the behaviors that we see here, we really want to think back to last week and we talked a lot about stigma. A lot of people also may be experiencing their own internal stigmas and shame when they come in to the clinic for their treatment services. Again, this was like a super crash course in this, but it's important to understand and recognize what trauma can look like, how we can recognize a patient is experiencing a trauma response, so we can help them feel more safe in our care, which ultimately leads to better treatment outcomes and more positive experiences for us as a provider as well. Again, these are just more examples of the impact that trauma can have on individuals. You can see trauma can impact multiple domains, including our emotional, behavioral, physical, developmental, and cognitive, also interpersonal, those relationships, as well as spiritual. Trauma really does have an impact on all different aspects of our lives and our patients' lives and how they interact with us as providers and in their treatment program as altogether. It's important to recognize that over 75 percent of people who have substance use disorder of any kind have experienced some type of trauma in their lives. It really is important for us as providers to understand how to actually navigate and work with these people who have experienced trauma. Now, we're going to dive into a little bit more trauma-informed care specifics. Trauma-informed care, also trauma-informed approach, is a way of working within our organization, so a program or an organization or a system that has really adapted these trauma-informed concepts. They have trauma-informed realizes the widespread impact of trauma and understands potential paths for recovery. The organization recognizes the signs and symptoms of trauma in clients, families, and staff, and others involved with the system, and responds by fully integrating knowledge about trauma into policies, procedures, practices, and seeks to actively resist re-traumatization. It's an entire way of approaching health care that is truly based on understanding trauma. On every level, the organization takes a look at making sure their staff understands trauma, understands trauma responses, and so on and so forth. We'll dive more into the how and what this is in just a moment. When it comes to trauma-informed approaches, SAMHSA, of course, has developed different helpful tools. This is the six guiding principles for organizations and individuals to utilize that help to guide a trauma-informed approach. These principles, really what they're ultimately trying to do is to increase provider awareness of the impact that trauma can have serve and in the communities that they serve as well. The principles include safety, trustworthiness, and transparency, including peer support, collaboration and mutuality, empowerment, voice, and choice, and cultural, historical, and gender issues. SAMHSA recognizes that adopting a trauma-informed approach is not just accomplished through one particular technique or one checklist. It requires this constant attention, awareness, sensitivity, and really an entire cultural change at your organizational level. Again, we're going to dive into this in just a moment. The four R's of trauma-informed care is another really important piece of this approach. We need to make sure that as an organization and as an individual, we realize the widespread impact of trauma and understand that there are the potential paths for recovery. We recognize the signs and symptoms of trauma in clients, families, staff, and anyone else involved in the system. We respond by fully integrating knowledge about trauma into our policies, procedures, and practices, and we resist re-traumatization of children, as well as the adults who care for them, and of course, the adults that we're actually caring for as well. The relevance of trauma-informed approaches in our work. Essentially, why is this important? It's really important to understand the importance of trauma-informed approaches, because we need to understand that trauma or traumatic experiences have a direct impact on people's overall health and well-being. That's both for our clients and the people that we serve, as well as ourselves. We need to fully understand that traumatic experiences have a direct impact on how people engage in the services and the care that they receive. We need to understand that if someone discloses current or past trauma, that it's our job and it's really important for us to know how to respond. That goes for whether you're a clinician, a provider, or you work at the front desk. It's super important to know how to respond when somebody discloses some trauma or is in a trauma response. It's really important for us to recognize and know the impact, because ultimately, this will help us to improve health outcomes for the people that we are serving. As much as we are really, truly doing all that we can do all the time to provide the best care for our clients and our patients, sometimes, unfortunately, we are all still potentially re-traumatizing our patients. Most of the time, we aren't aware that we're doing this, but some of the things that can possibly help re-traumatize our clients could be even from just having a lack of privacy, whether it's at the front desk or having conversations where other people can hear. There could be some staff bias, so it's really important for us to look at our own biases and make sure that we're not biased when it comes to any particular race, ethnicity, gender, gender identity, sexual identity, or class. Sometimes, even unwanted physical touches, even when they're well-intended, like maybe a pat on the shoulder or something simple that we think might be just innocent could be enough to trigger something in a patient. Sometimes, it's even as simple as how we ask personal questions or if we're talking to our clients as though they are maybe below us, like we are the expert and they are the ones that need our expertise. Working with that hierarchical approach can be traumatizing. If we're looking at things and having a conversation that maybe there's only one right way or an either-or thinking in how we approach complex situations, this can be traumatizing. A big one is having rigid, rigid policies or procedures in the clinical setting. I have a great example of rigid policies coming up. It's just really important to really look at how we're approaching all the things that we do because there are potentially ways that we might be re-traumatizing patients without realizing it. If someone is experiencing a trauma response in the clinic or has at one point ever experienced re-traumatization in a healthcare setting, then they may be more avoidant when it comes to coming to the clinic or they might have a fear of not feeling heard or being taken seriously when they're speaking. They may fear placing trust in others or they might feel like they're being controlled by us or worried that they're going to be abandoned or exploited. Another thing that I want to mention too is difficulty keeping appointments, so following up on referrals, following through with plans. This is when it comes to having some of these rigid policies and procedures when we're working with patients with substance use disorders. Again, often they have experienced trauma. Both trauma and substance use disorder diagnosis include things that make it very challenging for people to follow through or keep appointments. We want to maybe take a look at some of the rigid policies that we have for people who no-show to appointments. What is really going on? What are they really experiencing? Why are they not showing up to their appointments and how can we help? Rather than no-show policy, they can't come back or they can't get their refills or things like that. So, okay, there we go. Why a trauma-informed approach matters for both clients and providers? Well, of course, like I said before, people receive better services and care period when we're working with a trauma-informed approach. We're really taking everything into consideration and ultimately they receive better services. The staff are also able to cope more effectively with their work and is associated with greater resilience among workers. So, this also promotes staff retention and reduces turnover, reduces level of vicarious trauma experienced by staff. So, something that is often heard is trauma-informed approaches is also individual and self-care and organizational workforce wellness because it looks at the trauma from the patient-client point of view but also from the staff point of view. So, ultimately leading to much more happy workplace and healthy relationships between everybody. And again, bringing back this idea of needing to focus more on culture. So, as we know, culture affects every aspect of a person's life identity and identity and it really does shape a lot of their experiences. It's important for us to acknowledge our own racial or cultural biases that we might have, have honest conversations about these. So, that way we're checking ourselves before we are working with patients that also might have experienced some sort of trauma related to their culture or historical trauma. So, in regards to that, when we're looking and working with American Indian or Alaska Native folks, I just wanted to point out this here, like the effects of historical trauma. The life expectancy for American Indians or Alaska Natives is 5.5 years shorter than the total population. There's a higher risk of psychiatric conditions, suicide, trauma, substance use disorder, cancer, mortality, and diabetes. So, yeah, minority individuals often face multiple oppressions, meaning they could have you know, gender bias compounded by discrimination due to their racial or ethnic group or their religion or sexual sexual orientation, poverty or conditions of ongoing violence. This is a very interesting case study. So, Tommy is a 24-year-old male from South Dakota. He, his story is 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 gunshots, he would hear gunshots other times during combat, he would hear his Lakota ancestors speaking to him, saying not to worry, and he was going to live and be free from injuries or death. He added that his grandmother's voice often told him that if he did get shot to sing his death song, so ancestral spirits would be able to join him and provide care and assistance to the other world. So, he continued by saying that by keeping the traditional ways of abstaining from alcohol and working to help others who had first residual traumatic war injuries, he would be able to live with harmony and balance in all of his affairs. And he explained that this was the Lakota way, the great circle of life. So, what a beautiful story. Unfortunately, Tommy told this to a provider that was not culturally informed. And he was told, the provider told Tommy that he may be experiencing delusions or psychosis. So, you know, this is just an example of how Tommy really used his culture as his protective factor. This was something that he truly was using to help keep himself healthy and to cope with the trauma that he was experiencing and all of the fear that he had. And then to be told, no, no, no, this is a delusion. You're actually sick. So, then he started to question that himself. But this is just an example of why we really, really need to make sure that if we're working with different cultures, we need to fully, you know, do our best to be informed and, you know, see if we can, what we can do to help both use culture as prevention and culture as part of the treatment as well. So, if you're noticing that you have a patient that is experiencing some trauma-related behaviors in the office, I always like to recommend that folks have some sort of coping or soothing kit in their office or even at the front desk or in the waiting room that can really help patients feel more comfortable and grounded if they're triggered. So, just some of the examples are having, you know, things to like really, you know, get people engaged with their senses. So, sweet candy or sour candy, some different stress balls, fidgets, bubbles to help people breathe, Play-Doh, just all sorts of different things that can really help provide something to help people cope in the moment. So, here's another case study. So, if this, with this one, I might ask folks to come off mute to kind of talk this through or give me some other suggestions of how this could be done, could have been handled differently. But Brenda is a 20-year-old female. The emergency department of a busy hospital has a policy that requires nursing staff to confiscate clothes of people who are admitted for self-injury or suicidal feelings. The policy was developed to protect patients by ensuring that they do not have a concealed weapon. Brenda is a woman who has experienced a rape sometime before she reported it. She is admitted for self-injury and is asked to take off her clothes but refuses. Brenda is then held down by a male security guard while a nurse removes her clothes. Brenda's heart starts pumping. She can't think clearly and her breathing gets shallow and her fight, flight or freeze response kicks in. The ER staff used chemical and physical restraints and called the police to subdue Brenda. So, what was Brenda experiencing and what could have been a better way to approach this situation? And by doing that, the staff assaulted her again. Mm hmm. Yeah. What is some a different way they could have approached it while only staff offering to assist. Mm hmm. Yeah. So this is offering her to change out of clothing, piece by piece instead of taking off all of her clothes at one time, or making her go through that. Mm hmm. Yeah, so the staff essentially, you know, they, they had this policy that they implemented at one point, because they thought it would be the best interest for everybody, but ultimately retraumatized this patient tremendously. And this is just a, an example of how important it is to really assess your policies and procedures that you have. This is like a very intense example, but like what what can you do to, to really look at all of your policies and procedures to make sure that you're not unknowingly doing additional harm to your clients. Okay, now this is the point we're going to talk a little bit more about really how we can integrate trauma informed approaches into your organization. So I know you all may not have the ability to make your organization as a whole adopted trauma informed care approach, but I'm going to tell you, you know what that approach looks like, what are some of the steps that it takes to do that, and, you know, honestly you can all do this, little by little as an individual as well. I'm learning about it, about how you can change certain things and how you approach your work. Maybe, if your organization isn't quite ready to to adapt this as a whole. And this is something that, you know, I talked about it being a culture change. So it's a culture of trauma informed care that really is, is, is needing to be implemented. culture involves changing all aspects or at least assessing all aspects of the program activities, settings relationships in, and the atmosphere of the organization so it's not just implementing new services, it's changing kind of how your organization is already doing the services that they offer, so it needs to involve all groups from administration supervisors direct service staff support staff and the consumers the patients need to be, you know, engaged in this work as well involves making trauma informed leadership changes into a new routine. It's a whole new way of thinking and acting it's an entire new new new program essentially. And it takes a commitment to ongoing processes of self assessment review and hearing from the staff and from the patients, and then being open to changing these policies and practices along the way. So this saying here trauma informed leadership in the workplace fosters a culture of empathy, understanding, and healing for all employees. what difference does trauma informed care approaches make well improves works for improved workforce wellness. So, it essentially creates more of a sense of confidence and satisfaction in the work that is being done reduces burnout and stress. Overall improves organizational climate. It helps to create more integrated care within departments because you're kind of creating some more shared language and shared resources across the board, increasing engagement. So this means there's more follow through on appointments and classes, there's more, there's a reduced note show from our clients typically there's more adherence to plans or treatment protocols, more people are more likely to follow through on referrals there's reduced emergency room visits and just general and group satisfaction with care and services. So this is something called the parallel process, which is kind of, it's based off this something called the sanctuary model it recognizes that just as humans are susceptible susceptible to misapplication essentially of survival skills organizations themselves are equally as vulnerable. So, this is kind of meaning like this is reflected between the different systems. So, for an example of clients feel unsafe. The staff feels unsafe. Overall, the organization itself is probably unsafe. You know, angry aggressive clients usually create angry aggressive staff, and the organization has more punitive consequences for both. If an organization is overwhelmed. The staff are overwhelmed and the clients are overwhelmed. So, as you can see like these are kind of the negative parallel processes but you know we can also switch them around. Meaning, if clients feel safe the staff feel safe and the organization is safe. So, you know, intervening and changing, shifting the culture really helps us to shift behaviors. And align both client and staff and organization together. So we're creating a trauma informed organization. Trauma informed organizations provide again safe calm secure environment with supportive care system wide understanding of trauma trauma prevalence and the impact of trauma and trauma informed care. Cultural competence and consumer voice so hearing the clients voice self choice and self advocacy voice choice and self advocacy. And so this looks like including the clients to really be a part of their own treatment plan. Recovery consumer driven and trauma specific services and providing healing hopeful and honest and trusting relationships. How does your organization measure up. So this is a guide that is available online on the SAMHSA website. They actually created, it's pretty great, a guide to really help organizations implement trauma informed approaches in their clinic. So it's, it's pretty neat offers a lot of step by step guide. Again, here are the assumptions the four R's of of trauma informed care here are the principles the six principles that we talked about. And then these are the different domains that need to be involved in looking at creating a trauma informed organization, which I'm not going to dive into all of that, but I will show this kind of process. So, the roadmap to trauma informed care essentially, this is kind of what it needs to look like in order to fully adapt trauma informed care as a whole in your organization. So you start by, you know, getting some of the foundations going recognition foundational awareness agency readiness process and infrastructure. And then, moving forward is, you know, kind of the implementation phase. So it's what's really important to recognize is that, you know, as you see here there's curves and there's loops and all of that and this really reflect that it's an ongoing process. It's supported by continued education and training for staff and community agency wide communication to model transparency collaboration and authenticity that are just hallmarks of trauma informed care. So it's something that takes time to implement and needs to be done, you know, as an organization if you're interested in adapting it to really make sure it's done throughout the entire organization multiple levels for it to really be super successful. But again, like I said, if you, you know, if your organization isn't quite ready to adapt it there's things that you can do as an individual to really take some steps to move forward with understanding more about trauma, and how you can incorporate trauma informed care into your own personal services that you provide. So I'm not we don't need to really do this as a as a group if I think well we still have some time so if we want to talk about it this would be great but bringing it all together so really, you know, we're all on zoom so we can come off mute and talk about it. But discussing the importance of incorporating trauma informed care in your individual practice and in the organization so what what are the some of the things that you're doing well, either as an individual or as an organization, and what are some of the things that you personally would like to improve on or what your organization would like to improve on. Hi Stephanie, this is Marcia. Thank you so much for doing this presentation for us. And I'm just thinking, I'm reflecting on the case studies that you went over and how when we look at our policies, you know, because rules that have worked before in the past, we didn't, maybe we're not taking in all this information. And so as for me, I think that now when I'm looking at policies and how things have, you know, kind of always been done that I'm going to be taking a different look at it to see if there's some way that we can take this information and do it better. Yeah, for sure. There's a lot of good resources available also to kind of help guide you as you start to look at the different policies and procedures you have. There's that framework back here on this, this guide is a great way to start. There's, I would recommend that I can send you the actual link, but if you were to go onto the SAMHSA website, or even just Google practical guide for trauma-informed approach SAMHSA, this should pop up as a PDF that you can download. And it's really great to help you kind of get started. But I think you, there's also, you know, people who do technical assistance that can help organizations kind of take this a step further as well. Thank you. Does anybody else have anything they want to add? All right. Okay. Well, that is what I have for you. This is a QR code. This will also probably be sent. I'm guessing Emily will put it in the chat for an eval. And I think that is what we have. And Emily, I will let you let folks know about the CEUs. Yes. Thank you, Stephanie. So yeah, I did put the survey link in the chat. I also linked that guide that you were just referencing on SAMHSA. So yes, Kelsey will be sending out the recording, which will be available in about two weeks. And once she sends that out, there will also be instructions to access CE. I don't think she sent out the first one yet, but yeah, it looks very similar to these instructions on the screen here. But we, it's pretty straightforward. If you have any issues with that, feel free to reach out to Kelsey, but those instructions will be coming. But yeah, I think that's all we need to share. So does anyone have any last questions or comments? Yes, yes, we can absolutely share the slides. I will make sure they're on the website where the credit is accessed, but we can all also have Chelsea send those out. Awesome. Thank you all so much. I appreciate it. Being able to spend my time speaking to you all, and maybe I'll work with you again in the future. Thank you. Thanks, Stephanie. Have a good night, everyone.

Stephanie Stilwell

trauma-informed care

substance use disorder treatment

clinical settings

principles of trauma-informed care

case studies

creating a trauma-informed organization

policies

retraumatization