Presentation

Facilitating Recovery Through…
Trauma-Informed Practices
and Trauma Specific
Interventions
Niki Miller MS, CPS
nmiller@ahpnet.com
Senior Program Associate
Cathy Cave
ccave@ahpnet.com
(N.Miller, 2011) 1

Part I -- Introduction
The Big Picture in Healthcare and Behavioral
Health with Regard to Trauma.

Goals of this Session
►Differentiate trauma-informed from trauma
specific services.
►Recognize adaptive behaviors and the effects of
trauma.
►Learn about practices and strategies that
minimize trauma responses.
►Know the types of trauma-specific interventions
clients can access.
►Prepare yourself and co-workers to deal with the
effects of working with people with trauma.
3

SAMHSA’s Strategic Initiative: Trauma &
Justice
→Trauma-informed practices are important for all human
service systems. Trauma specific services can hasten
recovery for many clients.
→In the absence of trauma-informed care, a trauma survivor’s
path is often marked by multiple failed encounters with
social services agencies.
→Until it leads to the most costly of all social service systems:
the Criminal Justice System.
“Reducing the pervasive, harmful, and costly health impact
of violence and trauma by integrating trauma-informed approaches
throughout health, behavioral health, and related systems and
addressing the behavioral health needs of people involved in or at
risk of involvement in the criminal and juvenile justice e systems.” SAMHSA,
2011

Understanding Trauma
Part II

Understanding Trauma: How Traumatic
Events Differ from Bad Experiences
• Experienced as threat to life and limb or
bodily integrity of self or someone close
• Experienced as terrifying, sudden and out
of the ordinary; feel helpless, hopeless and
fearful.
•
• Extreme stress that overwhelms a
person’s ability to cope
(N.Miller, 2008) 6

Male and Female Responses to trauma differ:
Externalize-male
Internalize-female
► Men tend to have more externalizing responses and women have a greater g
number of internalizing responses.
► Men are more likely to be exposed to violence, but less likely to develop
mental health problems from exposure.
► The most common traumatic experience men report is seeing someone
killed or seriously injured.
► Women are more likely to be sexually abused and assaulted and more likely
to be victims of childhood abuse.
► At least twice as likely to develop serious mental health problems as a result
of trauma.
(N.Miller, 2008) 7

Primal Responses to Threat
Fight- hyper vigilance on conscious and
unconscious levels, and flooding of physiological
changes related to aggression.
Flight- blood flows to the limbs preparing to run,
although flight is often thwarted and there often is
no relief or outlet. Avoidance, dissociation, hiding
and other psychological “flight” behaviors become
disruptive.
Fright- responding with a state of terror, often to
seemingly benign triggers; fright and anxiety
permeates all areas of life. Shortness of breath,
startle responses, sleeplessness.

Primal Responses to Threat
Freeze- response observed in animals, accompanied by
slowed and shut down metabolism. Attempt to remain
safe and invisible, dissociative, paralyzed ----actually
makes the survivor vulnerable. Dissociative response
reinforces helplessness in each new situation.
Flail- Perceived as aggression, but physical movement, such
as flailing of the arms, is meant to create a safe space
around the body rather than connect with a target. As
when lizards, birds or fish puff up or fan out to keep
aggressors from closing in.
Shield- Protective, like flailing, shielding and raising hands
over head and body, physiologically prepared for injury.
Shielding in response to noises or non-violent conflict.

Primal Responses to Threat
Flirt-Particular to women as a result of sexual violence
against women, especially as children. Instinctive placating
behavior for little girls sexually abused in violent homes.
Incest perpetration is more likely for daughters whose
fathers are violent toward the mother.
Submit- Renders the victim vulnerable, but more in control.
Animals will submit to predator if flight is impossible and
play dead. Submission and under arousal in the face of
danger. May be labeled “risk taking” behavior.

Resilience Factors that Reduce the Impact
► Seeking out Support from Other People, such as Friends and
Family
► Finding a Support Group
► Feeling Good about One’s s Own Actions in the Face of Danger
► Being Able to Act and Respond Effectively despite Feeling Fear
► Having a Coping Strategy, a way of getting through the event
and learning from it
Source: Miller, 2011

Triggers
► Substantial research shows trauma symptoms and
responses can increase when survivor’s begin
treatment/abstinence from substances.
► Triggers can become more pronounced and often are
shared triggers for both trauma and drug and alcohol use.
► 2/3 of men and women in addictions treatment report
incidents of childhood abuse.

Triggers: Harriet
“When I was on probation I had to go to a substance abuse
group with a bunch of other probationers. Every week I
dreaded going. Most of the time, I got high afterward. I
never said anything, missed as many groups as I could,
and took off the minute it was over. The counselor’s
summary said I was resistant to treatment and refused to
participate. I never knew why I hated it so much until I
learned to identify my triggers. There was only one other
woman in the group and about six guys, four of them wore
leather jackets—it was the smell. When I was 15, I took
off with a group of bikers to party one weekend. To make
a long story short, they raped me in a field near my school.
I just can’t be around the smell of leather.”

Consider What a Person Who is
Homeless Has Already Survived
What are they surviving now?

PART III Trauma-Related Mental
Health Challenges
15

Trauma-Related Mental Health
Challenges
►What is Post Traumatic Stress Disorder?
►What are the symptoms?
►What other mental health problems do
survivors have?
►How are they treated?
16

Post-traumatic traumatic Stress Disorder
Avoidance
• Voluntary suppression of memory
• Restriction of daily activities
• Dissociation; substance use
Arousal
• Startle reflex
• Irritability and vigilance
• Sleep disturbances
Intrusion
• Flashbacks
• Nightmares
• Trauma Re-enactment
enactment
(N.Miller, 2008)
17

Changes in Arousal, Attention,
Perception and Emotion
Arousal
Extreme levels of excitability and responsiveness to external
stimuli or numbing and detachment from the outside
world.
Hyper-arousal←←←→→→numbing
Attention
The mind’s energy is directed away from situations,
completely inattentive and absent or toward them, deeply
and exclusively focused.
dissociation←←←→→→ hyper-focus

Changes in Arousal, Attention,
Perception and Emotion
Perception
Pupils dilate: vision and hearing are sharpened or dulled and
memory is absent
heightened←←←→→→dulled
Emotion
Feelings are devastating and painful or inappropriately
detached from experience.
absent←←←→→→overwhelming

Trauma and Mental Health
►Depression
►Anxiety
►Agoraphobia
►Addiction
►Personality Disorders
►Dissociative Disorders
20

Part IV
Trauma-Informed Practices

Applying Trauma Informed Care to Human
Service Settings
► Universal strategies address entire groups that
share the same general risk.
► Universal strategies are applied to groups without
any prior screening, when the entire group is
capable of benefiting.
► Universal assumption that trauma has occurred
22

Do No Harm
Trauma informed
►All staff understands trauma and its impact
on the recovery process.
►Services have been designed to enhance
safety, minimize triggers, and prevent retraumatization.
►Relationships between staff and clients are
based on healing and equitable distribution
of power.
►Trauma survivors are empowered with
information, referrals, and hope.

Trauma specific
Do No Harm
►Clinical and program staff have specialized
training in trauma treatment and recovery
practices.
►Specific groups and interventions are aimed
at reducing effects of trauma and increasing
knowledge and coping skills
►Skills development empowers survivors to
manage the aftermath of victimization and
trauma.

Four Principles for Homeless Services
(Hopper, Bassuk & Olivet, 2010)
1.Trauma Awareness- training and education,
practice based in theory, expertise and research;
staff development
2. Emphasis on Safety- physical and emotional
safety, predictability, consistent boundaries,
respect, culturally responsive, minimizes re-
traumatization, , healing relationships
25

Four Principles (Hopper, Bassuk & Olivet, 2010)
3. Choice and Control- minimizes power
imbalances, involves consumers in service
design, delivery and evaluation, empowerment
model
4. Strength-based and Empowering- focus on
resiliency, recognizes adaptive behaviors as
survival skills, recognizes and builds on
strengths, instills hope
26

Trauma-Informed Environment's
► Creating safety is primary; the safer and more predictable the
service environment, the better the engagement.
► Services have been designed to enhance safety, minimize
triggers, and prevent re-traumatization
traumatization.
► Education and information about trauma and recovery is
incorporated into services delivery.
► All staff understands trauma and its impact on the recovery
process, relationships, and on staff’s s effectiveness.
► Power-sharing is the basis of helping relationships that are
founded on respect, information, connection and hope.

Trauma-Informed Services
Staff Training
Consumer/Survivor Education
Reducing Triggers
Dealing with Unavoidable Triggers
Calming, Grounding and De-escalation
Present-day Focus on Symptoms
Support for self awareness and self care
Peer Support

Foundations of Trauma-Informed Care
► Principles of trauma-informed care see substance use and
other behavioral health problems as adaptive responses to
trauma.
► The assumption of a trauma history guides every
encounter, at every level of care, whether or not clients
disclose or even remember trauma.
► Responses and defense mechanisms are reframed as
survival strategies that served a safety function and are
recognized as evidence of strength.
► The goal is to empower survivors with knowledge and skills
so they can take care if themselves, feel a sense of choice,
internal control and autonomy.

Screening—assume a trauma history, but
always screen for current safety.
If screening for past trauma, then guidelines are
helpful.
► Wait to screen after the person has adjusted
rather than upon admission
► Explain the screening in advance, how the
information will be used to benefit him or her,
then ask if you can continue.
► Use valid screening tools that focus on presentday
symptoms. Use a checklist when asking about
past abuse rather than an interview.

Screening—assume a trauma history, but
always screen for current safety.
► Tell them that yes or no answers are fine unless
they wish to say more.
► Give her or him as much control as possible,
including passing on questions, taking breaks etc.
and choosing the setting.
► If the client becomes too upset, redirect by talking
about their strengths, the present day, and ask
them to talk about how they have gotten through.
Trauma screening tools can be found at the
National Center for PTSD.

Trauma Stabilization and Psycho-Education
► Grounding—directing attention to the “here-andnow”
and away from sensory recall of the past,
negative experiences, and emotional states.
► Self-soothing—preparing a menu of comforting
and calming procedures in advance of a response
that they can use when emotions become
dysregulated and arousal is high.
► Self-care—learning to self-monitor emotional
states, evaluate choices and actions, and actively
pursues emotional, mental, and physical healing.

The Institute for Health and Recovery has
created a safety tool to help trauma survivors
use calming strategies to cope with triggers.
Work with people to answer the
following questions:
►What are your triggers?
►What are your early warning signs?
►How do you know that you are becoming
emotionally overwhelmed?
►What helps you calm down when you are
upset?
►What can staff members do to help at those
times?

PEACE is an acronym for one approach
to cope with unavoidable triggers:
►
►
►
►
►
Predict and prepare—“When we go to court, your husband will be in the
room. Tell me what steps would make you feel safest in court?...What would
you like to do to take care of yourself afterward?”
Enlist—“What has helped you in the past not to drink when you had to deal
with your mother yelling at your kids?”
Acknowledge—“Many women have a difficult time when we have to give a
urine sample—it feels invasive. I can understand why it makes you anxious.”
Choice and control—“We have to go through everyone’s belongings to make
sure nothing unsafe comes into the facility…would you like to be in the room
when I check yours or should I do it while you are with the nurse?”
Explain—“We ask each person to go through the metal detector to check for
anything unsafe that might come into the building. If you turn your back
toward me I won’t have to reach around you. I will need to run this wand
alongside you. Would you mind putting your arms out?” (Miller, 2010)

PERCEPTION TRIAD
►Non-intervening
witness
►Enlightened
witness
Abuser
Rescuer
Victim
(N.Miller, 2008) 35

The RICH Model
(From Risking Connections- Sidran Press)
► Respect—this may be a very different response than expected. It can
be challenging to convey respect consistently. Survivors may view
staff as authority figures or through the lens of past abuse.
► Information—let everyone know what is going to happen and why.
Education on the relationship between trauma and substance use and
how others have successfully overcome the effects of trauma.
► Connection—with the here-and-now and senses, connections with
people, and internal connections; between the mind, body and spirit,
between actions and values. Safe connections with others re-write the
patterns of abuse within relationships and ground survivors in today.
► Hope—remind survivors of their many strengths; that they have
survived many things; recount their recent successes, small victories
and strengths. The successes of others in recovery helps sustain hope
for staff and clients alike.

Trauma Informed Peer Support
Fundamentals
►Peer Support is rooted in:
• A natural human response to shared
adversity
• The desire for healing & growth
• Compassion for self and others
• Consciousness-raising

Peer Support Principles
Regardless of the setting or type of
activity, peer support is based on
the following principles:
►Voluntary
►Non-judgmental
►Respectful
►Reciprocal
►Empathetic

Peer Support is NOT
►A “program model”
►Focused on diagnoses or deficits
►About “helping” others in a hierarchical way
►Being a “counselor”
►Pressuring people to comply with treatment
►Monitoring people’s behavior

Peer Support Fundamentals
Peer support promotes growth and
healing through:
• Building reciprocal relationships among a
community of equals
• Learning from each other
• Taking action

Trauma Recovery
► Recovery from trauma encompasses multiple aspects of
people lives, involves changing deep-seated beliefs and
gaining knowledge and skills that restore a sense of
choice and control.
► The assumption of a trauma history guides every
encounter, whether or not clients screen for, disclose or
even remember trauma and whether or not trauma
treatments are available.
► Responses and defense mechanisms are reframed as
survival strategies that served a safety function and are
seen as evidence of strength and resiliency.
► EXERCISE # 1

PART V
Trauma Specific Interventions
42

Trauma Treatment and Recovery
Treatment types
►Pharmacological
►Physiologically
►Past based
►Present based
(N.Miller, 2008) 43

60% of people with PTSD
improve with manualized
present day, symptom based
treatment.
Najavits, , 2007
(N.Miller, 2008) 44

Tasks of Trauma Recovery
Judith Herman (1992) identified three stages of recovery from trauma:
► Gain authority over the memory
► Safety
► Self-soothing
► Grounding
► Self-regulation/affect regulation
► Identification and elimination of triggers
► Grieving
► Empowerment

The Trauma Conversation, Redirecting
and Giving Voice
►Silencing those who have found the
courage to speak is as re-traumatizing as
delving and probing. Perpetrators of abuse
attempt to keep their victims silent.
However, if staff is spending a great deal of
time in discussion of the details of the past
abuse, it will take a toll.
►Modeling safe language to name
experiences and teaching boundaries in the
area of self-disclosure is also helpful.

The Trauma Conversation, Redirecting
and Giving Voice
►It is crucial to educate about trauma:
intrusion, the power of sensory recall, and
vicarious trauma. This is as important to
client self-care as it is to preventing
compassion fatigue among staff.
►Rules of thumb: allow clients to take the
lead on conversations, do not probe or
silence. Master simple re-directing
techniques , encourage self-soothing or
grounding if there is distress.

Manualized Treatments for Integrating Trauma Recovery
See Handout: Trauma-specific interventions with educational
components, that teach coping skills.
►Seeking Safety
►Essence of Being Real
►Trauma, Addiction, Mental Health, and Recovery
(TAMAR)
►Trauma Recovery & Empowerment Model (TREM)
►Addiction & Trauma Recovery Integration Model
(ATRIUM)
►Trauma Affect Regulation: Guide for
Education & Therapy (TARGET)
48

Women, Children and Sexual & Domestic
Violence
Trauma is devastatingly interpersonal for women
and children. It involves violations that are tragically
intimate or the threat of lethal violence from a loved
one. Betrayal accompanies these types of traumatic
experiences. They are the most likely to result in
serious mental health problems and a drastic
alteration in one’s assumptions about the world.
49

Thank you for bringing so many people home.
However, these types of events are NOT mental health
problems in and of themselves; they are crimes. And
sometimes justice is as healing and necessary as
counseling. And it is only just that human service
systems become trauma-informed, gender responsive
and culturally aligned. When gender and race intersect
with economic and health disparities, and vulnerability
to violent and sexual victimization is the result, justice
must be part of the answer.
SELF ASSESSMENT EXERCISE # 2 50

.
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