FAQ on Trauma-Informed Care for Peers Elena Cherepanov, PhD, LMHC, Certified Trauma Specialist Elena.cherepanov@cambridgecollege.

edu Chair of Trauma Studies programs in Cambridge College Summer, 2013

I want to thank Zohreh King, the Director of Recovery at North Suffolk Mental Health Association, whose enthusiasm and passion for Trauma-informed care made this paper possible and to North Suffolk peer specialists who generously contributed their thoughts, comments and questions.

What Trauma-Informed Care means and why its important for Peer Specialists SAMHSA defines Trauma-Informed Care as engaging with people with histories of trauma while recognizing the presence of trauma symptoms and acknowledging the role that trauma has played in their lives (http://www.samhsa.gov/nctic). There is a consensus in the field that many consumers of mental health services are trauma survivors and that their traumatic experiences shape their responses to services and supports. Disregarding the history of trauma increases the risk of re-traumatization, substance abuse, self-injury and other high risk behaviors. What does a Trauma-Informed approach mean in Peer work? 1. Acknowledgement that most individuals served in the behavioral health system have been exposed to trauma-inducing situations; 2. Understanding that exposure to a traumatic event affects everybody in a different way and may be a life-changing experience; 3. Awareness that psychological trauma affects an individuals sense of safety, perception, feelings, thoughts, and behavior. It determines how a person uses available supports, deals with crisis situations, and reaches out for help; 4. Acceptance of the universal nature of humans, individual uniqueness, and cultural specifics of trauma experience; 1

5. Prioritizing strength, survivorship and overcoming feelings of weakness and victimization; 6. Educating service providers and advocating for the need of trauma-sensitive services. Is trauma always pathological? Post-Traumatic Stress Disorder (PTSD), which is a chronic condition that affects a persons daily functioning, develops only in a small percentage of cases. Most individuals are able to cope successfully with traumatic exposure, which can also lead to post-traumatic growth and opens the opportunity to learn about themselves and the world and better relate to and help others. Each traumatic experience is unique, but they all share the universal characteristics of feeling unsafe, helpless, victimized and powerless. Feeling unsafe or threatened can trigger an incongruent response, or overreaction, to a crisis, such as confusion, avoidance or even violent behavior. This explains why some crisis interventions, like the use of restrains in the mental health system, can be particularly re-traumatizing for those who were abused in the past as this brings back the old memory of being powerless. Its impossible to avoid all of the adversities of life and most post-traumatic reactions are expected and normal The severity of traumatization depends on the nature of the event, personal history, pre-existing vulnerabilities, coping resources and supports. Pre-existing mental health issues, past history of trauma, substance abuse, psychosocial stressors such as social/personal/cultural isolation; cognitive limitations in the processing of information; poor medical health all of this complicates coping. Trauma is defined by how a person copes with the event. However, there are some particularly traumatizing events that are more often than not associated with PTSD; among them is sexual trauma, child abuse, loss of a child, and the suicide or violent death of a family member, friend or co-worker. How can a Peer recognize the presence of a history of psychological trauma in an individual? Traumatization affects a persons feelings, reactions, behaviors, relationships, or choices. A traumatized person May avoid discussions, situations and places that bring back traumatic memories. If triggered, the person can overreact to seemingly minor stressors;

Can have difficulties disclosing and discussing traumatic experiences; Can feel vulnerable, unsafe, and fearful or threatened even when nobody threatens them;

Can easily become overly emotional and overwhelmed; Has issues with trust, i.e., the world is out to get me; Expects that traumatic experiences will repeat in the future; May have poor boundaries and have difficulties: o With identifying their own needs, especially in the area of interpersonal interactions; o With recognizing and respecting their own and anothers personal space and boundaries; o o With setting limits, like saying "No" to things that are not good for him/her; With taking ownership of a problem.

The effects of the traumatic experience are not always negative. Trauma can lead to personal growth and, as a result, a person becomes more mature and is able to understand others. The role of Peer in TIC The role of a Peer in providing trauma-competent care is very important. Peers contribute their personal experience of recovery and overcoming to support and inspire those struggling with traumatic impacts on their life. Peer Specialists are very familiar with stigma, prejudices, and discrimination stemming from the misconceptions and myths about mental illness. Peers are in special positions to empower others by relating to the struggles of recovery, to offer compassionate support for a persons mental health needs and to advocate for trauma-informed services. A Peer Specialist

a. Provides trauma-competent support, education, guidance and encouragement to survivors of trauma using their personal experience of survivorship and overcoming trauma by emphasizing personal strength and past survival experiences; b. Restores the survivors sense of personal importance, integrity and dignity; c. Asks about a persons traumatic past, helps to identify triggers leading to past crises, and assists with developing a crisis prevention plan; d. Assists with developing a coping tools box; e. Is mindful about ones own trauma history, counter-transferences and triggers and seeks help if this interferes with helping others. How to use Self-disclosure Peers provide support and empowerment using self-disclosure about similar struggles and success in recovery. Having a shared experience offers a unique perspective and allows for a better understanding of what a traumatized person goes through. As with any other instrument, self-disclosure can become problematic and even unsafe if not used correctly. Problematic self-disclosure Peer unnecessarily shares personal stories with excessively graphic details; Peer discloses third partys personal information; Peer shares irrelevant and excessive personal information, i.e. home address, what school kids go to. Peer discloses insider knowledge of a service organization or providers; Disclosure exclusively revolves around suffering, failure and negative outcomes; Peer competes for attention, i.e. my experience is more traumatic than yours.

Helpful self-disclosure Is selective, content limited, situation specific and is tied to current recovery tasks; Normalizes a person's feelings; the person learns that there are others dealing with similar trauma and mental health issues Focuses on overcoming, recovery, newly found strengths, resources and hope. 4

How can we control triggers? It is impossible to control all the triggers that a person may encounter. However, its possible to assist in recognizing reminders of traumatic experiences, to have a coping plan in place and to reach out for help, if necessary. Some triggers are more predictable than others. E.g., an anniversary can trigger memories of loss. A Peer Specialist can assist with planning ahead and having supports in place. The Peer Specialist may help the person plan not to be alone, or to keep themselves busy. How to help a person to identify sources of strength Peers can help with the identification of a strength by asking, W hat helped you to survive and what keeps you going? Some of the answers may include Sense of Humor Caring attitude Love Family or community social supports Good memories from the past Never give up attitude Cultural identity Spirituality

What to do when a person dissociates or just doesnt want to talk about a traumatic experience Avoidance often follows traumatization--a person may not want to talk or even think about trauma because its too painful. Dissociation is a type of avoidance--a person dissociates when feeling unsafe and overwhelmed by painful memories.

When helping a traumatized person, it is not productive to talk only about unpleasant things. A lot more can be done, including establishing a trustful relationship, while discussing positive experiences and what a person enjoys doing. If person mentally wanders away, a Peer Specialist: 1. Ensures the person's safety; 2. Gives a person space and time to deal with the flood of memories, offers to use grounding techniques (see Attachment) and welcomes him/her back when he/she is ready to continue; 3. Does not force a person to talk about traumatic experiences; asks instead what this person wants to talk about. If a person tells a Peer that he/she doesnt want to talk about what happened, a Peers response can be, Thank you for letting me know. When you feel ready to talk about it, I am here to listen; 4. Does not leave a person in distress alone. If a person leaves the room, a Peer should follow him/her to ensure safety and to be available when a person is ready to talk. When to ask for professional help If a person suffers, is severely depressed and feels unsafe; If a person feels like hurting himself or others; If trauma reactions are so intense and last for such a long time that they interfere with a persons daily life. Some Dos and Donts Do Give a human, comforting response and express empathy to a distressed person; allow a person to tell a trauma story and vent their feelings; Support the persons focus on here and now; Even if a person is not responding, tell a person that you know that he/she can hear you, and that they are safe now; 6

Treat a traumatized person with respect--they did the best they could, and should be given recognition for their efforts;

Respect personal space and boundaries; See a person behind the trauma; trauma affects different people in different way. Understand post-traumatic symptoms as adaptive rather than inherently pathological; Be sensitive to a persons cultural needs; Refer if you dont feel comfortable working with the person; Focus on strength, rather than on weakness; Always emphasize that a person is in control and has choices; Ask questions: What helped you to survive? What kept you going?; Facilitate personal post-traumatic growth. Dont

Dont say, I understand how you feel. Say instead, I cant imagine how you feel--so help me to understand;

Do not automatically assume that any exposure to adversity results in trauma; Do not coerce or force a person to share what happened; Dont use the word Victim--use the word Survivor instead; Dont be judgmental. A Peer Specialist must be aware of his/her own biases, stereotypes and prejudices;

Dont promise anything that you cant deliver: Dont say that everything will be all right, even if you want to believe in it yourself;

Do not tell war stories; Do not compete with the person served for attention; Dont tell people how they should be feeling or thinking; 7

Dont tell people that what has happened to them is a result of something they have done;

Dont criticize services that the person may depend on; Do not give up hope. What if the person doesnt trust me?

Trust is a learned behavior of taking a risk and putting confidence in someone. A traumatizing event is sometimes experienced as a betrayal of trust. A traumatized person may feel too vulnerable to open up to others and have a hard time reaching out for support and allowing others to help. Once trust has been violated, its difficult to trust anyone again even though trust is the foundation for any secure and successful relationship. Sometimes traumatized people cant even tell if they trust someone, especially when they have no past experience to base it on.

Trust is not given and must be earned. There is no expectation that a traumatized person will automatically trust a provider, even when this provider is a Peer. It takes time to establish a truly trustful relationship. Through a consistent, supportive, predictable and stable relationship with the Peer, a person makes small steps in learning to trust again in a relationship and in general. Trusting the Peer can be the first step in developing the ability to trust others. It is okay to let a person served know that you dont expect to be trusted right away and that you hope to gain their trust in the future. Balancing compassion and safety Ensuring safety is of paramount importance in any trauma work. When feeling unsafe or threatened, a traumatized person can overreact and respond with anger, or even violence, to seemingly minor stressors. In order for the interventions to be effective, both the peer and the person served must feel and remain safe. Peers who focus on empathy, hope, understanding and compassion may easily overlook behavioral safety concerns. In cases of crisis, the trauma-informed approach means always offering choices. It is important to know a persons history and to be trained in risk management and non-violent trauma-informed crisis response. 8

Addendum Here is a list of grounding techniques that can be used when a person dissociates. These ideas were compiled by M.B. Williams and S. Poijula (2002) in their "The PTSD Workbook" (2002) iii. Focus on something you know to be real in your immediate environment, then blink your eyes hard while staring at it. This can break up the flood of visual memories that some people experience with flashbacks. Move around. Just changing your body position can break the flow of physical memories, bringing you back to the present reality. Really move around. Get up and walk around. The exercise can increase blood flow and add real sensory input from your environment, interrupting the flashback. Use a deep breathing exercise. The extra oxygen to your brain and concentration on the simple life-act of inhaling and exhaling can help to reign in your runaway thoughts. Do you have a safe place? Somewhere to go that is calming and restoring? Go there. Actually, physically go there if possible. If you can't get to your safe place, use visual imagery to go there in your mind. Put that vivid imagination of yours to work on something positive and calming. Look around you. What's there? Start naming things off out loud. Identifying real objects around you and the sound of your own voice can help to ground you in reality. Carry or have in your environment a "safe object" that reminds you of what is real and true. Grab your safe object and hang on, reminding yourself of truth and reality. Listen to a soothing tape or CD or MP3 file. This can be your own voice calmly and confidently speaking truth, a recording of your therapist's voice or words, a good friend or loved one's reassurance, or calming music. Whatever works for you. Clap your hands. The sound and feeling can banish unwelcome sensations. Stamp your feet on the floor. This is the same idea as clapping your hands, but gets more of your body mass involved.

Splash cold water on your face. The changes in temperature, pace of breathing and body position all help to remind you of the present reality.

Gently wash your face... this can help by symbolically washing away unwanted thoughts and memories and reinforcing feelings associated with positive self-care, self-affirmation and self-esteem.

Say positive things about yourself. It helps to have these truths written down somewhere, (like a card in your back pocket, wallet or purse) or have a short list memorized that is easy to repeat during the stress of a flashback.

Pretend to spray the memory away with all-purpose cleaner until it dissolves in front of you and melts into a puddle on the floor.

"Project" the flashback onto an imaginary whiteboard in front of you, then erase it. Actually move your hand back and forth and do the erasing motion, watching the memories get wiped away.

Draw the flashback, or a symbol or scene of it, then destroy it. You can sketch with a pencil on paper, use crayons or markers or anything at hand, then shred it or burn it or bury it.

Lock the flashback away from yourself in some type of container or vault. You can do this with a real piece of paper, that has a description or narrative or drawing of the flashback, or do it symbolically in your head. You may have to try a few things before you find something that works for you. Be imaginative and use clues like your known triggers and the types of sensations that you experience during flashbacks to figure out what might work the best.

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Mary Beth Williams , Soili Poijula (May 15, 2002). The PTSD Workbook: Simple, Effective Techniques for Overcoming Traumatic Stress Symptoms. New Harbinger Publications; Workbook edition.

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