Trauma informed care

Question 1

What is trauma?

Answer 1

• “A traumatic event involves a single experience or enduring repeated or multiple experiences, that completely overwhelm the individual’s ability to cope or integrate the ideas and emotions involved in that experience.”
• Has negative effects on the mind, body, and/or spirit of the individual who has experienced it
• Can be singular or multiple event
• About overwhelming our ability to cope
• Engenders a sense of hopelessness
• Can impact mental health, physical health, and spirit
• They can imprint on people and shape their experience of the world and their worldview in fairly significant ways
• Anyone can experience trauma
• 76% of Canadians experience some sort of trauma in their life

Question 2

Common elements of trauma

Answer 2

• Not the event that determines trauma, but the individual’s experience and the meaning they make of it

Three common elements:

• Unpredictable
• Could not be prevented
• Could not be escaped
• Sudden loss of a loved one, car accidents, sexual violence, physical violence, etc.
• But can be embedded in other experiences i.e. the experience of birth, incarcerations, terrorism, natural disaster
• Regardless of the nature of the trauma itself; it’s contained in three common elements
• It’s beyond the person’s control

Question 3

Types of trauma

Answer 3

• Single incident trauma
• Complex or repetitive trauma
• Developmental trauma
• Intergenerational trauma
• Historical trauma

Question 4

Single incident trauma

Answer 4

• Have a defined beginning and end

- i.e. car accident, single episode of sexual assault, witnessing violence

Question 5

Complex or repetitive trauma

Answer 5

• Multiple traumatic events over a period of time
• No defined beginning or end or a series of events with a beginning and end happening in a row
• i.e. ongoing episodic abuse, neglect, witness domestic violence, often involved being trapped emotionally and/or physically for a linger durations

Question 6

Developmental trauma

Answer 6

• Traumatic event experienced during childhood, usually repetitive
• Can interfere with child ability to develop healthy attachments
• Can alter their brain
• i.e. neglect, abandonment, physical, emotional or sexual abuse

Question 7

Intergenerational trauma

Answer 7

• Indigenous communities
• Trauma is passed down through generations
• Often seen in families with holocaust survivors
• Can exist with historical trauma

Question 8

Historical trauma

Answer 8

• Over the lifespan and across generations, mass group trauma,
• i.e. genocide, war, colonialism
• Historical and intergenerational can exists with each other

Question 9

Effects of trauma

Answer 9

• Fight or flight- traumatic stress response
• Range of physical and emotional reactions over the short and long-term
• We all experience some sort of stress response
• Shaking, pounding heart, rapid breathing, nausea/vomiting, lump in throat, cold sweats, dizziness
• Anxiety, terror, shock, anger, shame, emotional numbness, disconnection, intrusive thoughts, helplessness, powerlessness, irritability
• Most people will experience varying degrees of of these kinds of feelings for a while after the traumatic event
• With traumatic stress response we may seen these feelings persist longer

Question 10

The impact of trauma

Answer 10

• “The impact of trauma [can] felt throughout an individual’s life in areas of functioning that might seem far removed from the trauma.”
• Persistent state of emotional dysregulation
• Hyper-arousal and hyper-vigilance
• Dissociative state
• The effects of trauma may come up in unexpected ways in someone’s life
• Responses may not match the situations

Question 11

Resilience factor

Answer 11

• Resilience is both the capacity of individuals to navigate their way to the psychological, social, cultural, and physical resources that sustain their well-being
• And their capacity individually and collectively to negotiate for these resources to be provided in culturally meaningful ways
• Resilience plays an important factor on how people are able cope with trauma
• Recovering from that traumatic stress reactions
• Allowing to go on with life in way that brings meaning to you as you can find it

Factors of resilience

• General
• Relationship
• Community
• Cultural
• Physical

Question 12

Factors of resilience: general

Answer 12

• General factors which are intrinsic
• i.e. generally outlook on life, goals, aspiration, sense of humour, ability to solve problems, assertiveness
• All facilitate ability to get back to a sense of well being

Question 13

Factors of resilience: relationship

Answer 13

• Relationships with others
• Helps with coping and overcoming the stress
• ACES study
• With children, a positive relationship with an adult after the trauma can majorly help with ability to cope, physiological changes in the brain, mal-adaptations, etc.
  response

Question 14

Factors of resilience: cultural

Answer 14

• Religious or spiritual identification

- Cultural group support

Question 15

Factors influencing resilience: physical ecology

Answer 15

• Environmental factors; access to nutritional food, safe environment, etc. which can add or reduce stressors after trauma
• Physical ecology factors; nature bathing

Question 16

How trauma effects people (in a linear way - flow chart)

Answer 16

1) Trauma
2) Impacts our nervous system; fight, flight or freeze
3) Not able to stabilize; self-regulate; make distorted meaning of the event
or
Able to stabilize; self-regulate; grow; make positive meaning of the event
4) Significant and continued physical and mental health; behaviour; relationships; community and spirituality
or
Recovery of physical and mental health; stabilization of behaviour; resilience in persons, family, relationships, community, spirituality
5) All impacts:
Physical health - all aspects
Mental health - risk of mental health diagnosis, addictions, reliving events, suicide, hyperarousal
Behaviour - self harm, acting out, difficulty in school, maintaining employment, violence, crime
Relationships - conflict in relationships, couple, family breakup, children in care, attachment difficulties
Community - lack of support, isolation, difficulty seeking help, homelessness
Spirituality - despair, lack of hope, purpose or meaning
6) In turn influences:
- Health, seniors, family violence, healthy child
- Labour, education, justice, child welfare, workplace health and safety
- Immigrant, refugee, First Nations and Inuit

• Linear representation of the way people experience trauma and are able to stabilize their mental and physical health
• Make meaning after the event, or not
• Potential consequences of future interactions
• How someone can end up incarcerated after experiencing a trauma and not be able to get treatment after and the consequences or manifestations of the trauma not being resolved of coped

Question 17

Trauma implications

Answer 17

• Think of trauma as an injury
• Something that can be difficult to heal from
• Also needs to be a lot of conditions in place for that healing
• Even if it heals, it leaves a scar
• It can define your whole life, but it doesn’t have to
• It’s something you carry with you for your whole life

Question 18

How trauma effects people (in a linear way - flow chart)

Answer 18

1) Trauma
2) Impacts our nervous system; fight, flight or freeze
3) Not able to stabilize; self-regulate; make distorted meaning of the event
or
Able to stabilize; self-regulate; grow; make positive meaning of the event
4) Significant and continued physical and mental health; behaviour; relationships; community and spirituality
or
Recovery of physical and mental health; stabilization of behaviour; resilience in persons, family, relationships, community, spirituality
5) All impacts:
Physical health - all aspects
Mental health - risk of mental health diagnosis, addictions, reliving events, suicide, hyperarousal
Behaviour - self harm, acting out, difficulty in school, maintaining employment, violence, crime
Relationships - conflict in relationships, couple, family breakup, children in care, attachment difficulties
Community - lack of support, isolation, difficulty seeking help, homelessness
Spirituality - despair, lack of hope, purpose or meaning
6) In turn influences:
- Health, seniors, family violence, healthy child
- Labour, education, justice, child welfare, workplace health and safety
- Immigrant, refugee, First Nations and Inuit

Question 19

Trauma implications

Answer 19

• Think of trauma as an injury
• Something that can be difficult to heal from
• Also needs to be a lot of conditions in place for that healing
• Even if it heals, it leaves a scar
• It can define your whole life, but it doesn’t have to
• It’s something you carry with you for your whole life

Question 20

What is trauma informed care?

Answer 20

• Strengths-based framework
• Grounded in an understanding and responsiveness to the impact of trauma
• Emphasizes physical, psychological and emotional safety for both providers and survivors
• Creates opportunities for survivors to rebuild a sense of control and empowerment
• About reducing the technoloization of responses to trauma
• Understanding that people are just tyring to cope with what’s happen to them
• The belief that we can support people in feeling safe and building skills to prevetning further trauma from happening
• Emphasizing and placing priority on safety, control and choice
• Culture of non-violence and collaboration
• Universal precaution that everyone who walks through door has experienced trauma
• Helps us reframe what’s wrong with you to what happened to you

Question 21

Guiding principles of trauma informed care

Answer 21

• Acknowledgement
• Safety and Trust
• Choice, Control, and Collaboration
• Compassion
• Strengths-Based

Question 22

TIC guiding principle: acknowledgement

Answer 22

• Be trauma-aware
• Not necessary to dive into someone’s trauma history to be trauma aware
• Recognize that behaviours may represent adaptations to traumatic experiences
• Recognize the potential for clients to be triggered while receiving care
• Recognize the signs that a client HAS been triggered during care and be responsive in your nursing care

Question 23

TIC guiding principle: compassion

Answer 23

• Cultivate a positive emotional atmosphere; doing the little things
• Welcoming environment
• Attention to immediate needs
• Recognize that people’s reaction to you as a care provider may have nothing to do with you
• Validate what/how people are feeling
• Avoid labeling people or their behaviours
• Watch for and try to reduce triggers and trauma reactions
• Provide opportunities for new beginning; today is a new day with no mistakes in it
• Stay present

Question 24

TIC guiding principle: choice, control and collaboration

Answer 24

• Environment that fosters sense of self-efficacy, self-determination, dignity and personal control
• Involve the client in the decision-making process
• Ensure comfort during invasive assessments and procedures; make adjustments to these processes
• Allow the client to set the pace
• Communicate openly with clients about what to expect
  Ensure care goals are client-driven, not clinician driven
  Give as much personal control to the individual as possible

Question 25

TIC guiding principle: compassion

Answer 25

• Cultivate a positive emotional atmosphere; doing the little things
• Welcoming environment
• Attention to immediate needs
• Recognize that people’s reaction to you as a care provider may have nothing to do with you
• Validate what/how people are feeling
• Avoid labeling people or their behaviours
• Watch for and try to reduce triggers and trauma reactions
• Provide opportunities for new beginning; today is a new day with no mistakes in it
• Stay present

Question 26

TIC guiding principles: strengths-based

Answer 26

• View clients as resilient; all people have the capacity and all people have strengths
• Work with clients to identify their personal strengths
• Mobilize strategies that build on strengths and enhance clients’ abilities to develop new skills
• Teach clients how to recognize their triggers and develop skills in emotional self-regulation

Question 27

TIC guiding principles: strength-based skill building

Answer 27

• Self soothing
• Self trust
• Self regulation
• Self compassion
• Limit setting and assertiveness
• Communicating needs and desires
• Accurate perceptions of others
• Appreciating mutuality and reciprocity
• Recognizing fight/flight/freeze responses
• Gently challenges when people have concrete perceptions*

Question 28

Grounding techniques

Answer 28

• A set of simple strategies to detach from emotional pain
• Uses distraction to detach from overwhelming emotions and gain control over them
• Works by focusing outward on the external world rather than inward toward the self
• Is distinct from relaxation training and is a more effective intervention for people with trauma histories

Question 29

Grounding guidelines

Answer 29

• Can be done any time, any place, anywhere
• Can be used when faced with a trigger, when having a flashback, when dissociating, or when emotional pain goes above 6 on a 10-point likert scale
• Should be done with eyes open and lights on to help stay in touch with the present
• Refrain from talking about negative feelings
• Stay neutral
• Focus on the present, not the past or future

Question 30

Types of grounding strategies

Answer 30

1) Mental Grounding
- Using your mind to distract yourself
- i.e. listing all types of something you know (ice cream flavors) or counting

2) Physical Grounding
- Distract yourself away from what’s going on inside through physical sensations or movements
- Putting hands under cold water and paying attention to the coldness of water, jumping up and down and adding in clapping,

3) Soothing Grounding
- Take yourself through a particular ritual
- Say a particular thing to yourself

Question 31

Identifying other goals/interventions for healing: self-care inventory

Answer 31

• Associate only with safe people who do not abuse or hurt you?
• Get enough sleep?
• Do something pleasurable every day?
• Have at least one social contact every week?
• Have at least one recreational activity that you enjoy?
• Have at least one person in your life that you can truly talk to?

Question 32

What to do if grounding is not working?

Answer 32

• Encourage them to keep practicing; it’s a skill
• Something that becomes almost like second nature
• Practice even when they feel they don’t need it
• If someone is too heightened emotionally, it can be difficult to engage in grounding
• Want to engage on the way up; when feelings arise
• The earlier you can catch yourself and intervene the better

Question 33

Identifying other goals/interventions for healing: self-care inventory

Answer 33

• Associate only with safe people who do not abuse or hurt you?
• Get enough sleep?
• Do something pleasurable every day?
• Have at least one social contact every week?
• Have at least one recreational activity that you enjoy?
• Have at least one person in your life that you can truly talk to?

Question 34

Building skills in self-care

Answer 34

• Remember that people with PTSD often need to learn to take good care of themselves
• No one is perfect in doing everything on a list at all times
• The goal is to take care of the most urgent priorities first and work on improving self-care through daily efforts
• “Progress, not perfection”
• It’s a gradual process learning how to take to take care of yourself

Question 35

Being presence through attunement for TIC

Answer 35

• Makes us curious about people so that we look at our patients with deep interest
  Pay attention to what’s going on with them
• Causes us to notice body movement, facial expression, changes in muscle tone or respiration

Question 36

Practices of wondering in TIC

Answer 36

Wondering is a relational practice of curiosity that helps us understand each patient’s unique experience of illness and individual care needs

• What do you need when you feel overwhelmed?
• What do you need to feel safe during care?
• What’s happening emotionally/psychologically for you right?
• What makes you feel unsafe?
• What makes you mad?

Question 37

How do you engage in holding for TIC

Answer 37

• Maintaining therapeutic focus on the patient
• Keeping our patients/family members informed about what is going on now and what is coming next
• Sharing information with our patients/family members in a timely fashion
• Providing informed reassurance based on the realities of the moment
• Cultivating a sense of safety with patient
• Foster connection with people when they feel unsafe
• Need to sustain holding throughout the whole encounter

Question 38

Practice of holding in TIC

Answer 38

• Practices of holding are about helping patients and their family members feel seen and safe in our care
• Involves recognizing ways in which we can intentionally foster connection with our patients to cultivate a sense of security in a time of great uncertainty
• Particularly important for those who have difficulty feeling ‘safe’ in care environments such as those who have experienced trauma

Question 39

How do you engage in holding for TIC

Answer 39

• Maintaining therapeutic focus on the patient
• Keeping our patients/family members informed about what is going on now and what is coming next
• Sharing information with our patients/family members in a timely fashion
• Providing informed reassurance based on the realities of the moment
• Cultivating a sense of safety with patient
• Foster connection with people when they feel unsafe

Question 40

Language that fosters holding

Answer 40

I remember when you told me…
I’m sorry you had to wait; that’s not okay.
I’m here and I will…
You have every right to…
Tell me more about…
I will see to it that ____ is done for you…
I will help you; let’s…
Here’s what I know about…
Let me go with you and…
I will follow through until this is resolved.

Question 41

Language that diminishes holding

Answer 41

I’m sure you’re going to be fine
I’m sorry but I’m very busy today
I have other patients; I can’t be everywhere
I didn’t know because I wasn’t here yesterday
I was just trying to help
I’m doing the best I can for you
I wish you’d called me earlier
If aren’t able to be quiet, I’m going to have to ask you to leave
That’s not my job
Calm down

Question 42

Holding language: informed reassurance

Answer 42

• False reassurance vs. informed reassurance
• Not saying everything will be fine
• Instead you’re conveying important information that helps patients and their families understand what’s going on, the potential seriousness of it, and what you’re going to do about- preparing them about what possibilities they can expect

Question 43

Examples of informed reassurance

Answer 43

• Contextualizing
• Giving out possibilities
• Within the range of possibilities we are giving out information

This is what I’m seeing… these are my concerns…this is what we’re going to do about it…
The pain will subside shortly because…
We learned from your last appointment how to manage your ____ better this time.

Question 44

Self-care strategies for relational work

Answer 44

• Engage in your own self-care inventory
• Support from colleagues
• Written reflections
• Mindfulness practices
• Rituals