Trauma Informed Care
Emerging Practices for Emerging Adults Wayne Munchel LCSW Independent Consultant [email protected] Twitter @TAYtweetment
Katie Holloway Research Assistant Student [email protected]
Institute Objectives • Assess & apply cross-cutting service delivery principles to transition services
• Identify and evaluate key components of effective transition services, including engagement, trauma informed care, career development and early intervention psychosis • Share transition resources, tools and strategies
Dr. Evil’s TAY Program
2 Big Picture Questions How does current Medical Model impact young people? (Distress vs Disease)
How do we better support and promote healthy “Interdependence” ?
5 Key Elements of TAY Systems of Care Engagement Strategies/Retention Trauma Informed
Supported Ed + Emp
Integrated Sub Abuse
Is it safe?
Is it relevant?
Is it accepting?
Early Intervention Psychosis
Is it flexible?
90%
How we doing?
16
80%
14
70%
12
60%
10
50%
8
40%
6
30% 20%
4
10%
2
0%
0 Complete HS
Currently Employed
Post-secondary Recent Enrollment police/arrest/jail
TAY w/SMHC
General TAY Population
Duration of Employment (months)
The Good News “You suck less”
4 Principles of Transitional Services • Are you connected to your community? • Are you developmentally informed?
• Are you culturally attuned? • Are you oriented to Stages of Change?
Establish Community Partnerships – No one program can do it all
•No Wrong Door •Bridging •Peer Navigation Support •Warm Hand offs •Meet Survival Needs
Developmentally Informed? Meeting the challenge of recognizing & responding to developmental stage: • When we expect too little – children oriented (tendency to over protect, over help, avoid risk, condescend
Ave. Age of Emancipation = 32 y/o! • When we expect too much - adult oriented (tendency to assume youth have developed self-responsibility, goal directed skills, prematurely discharge
Culturally Attuned •Youth Culture
•Respectful Curiosity •“Independence”
Stage of Change Oriented? Matching Interventions to Stage of Change (Employment, Education, Therapy, Substance Use)
Engaging (while not Enraging) Youth & Young Adults
Katie’s Story
Engagement • Relationship = Resiliency • Strength-Discovery and Future Plans (TIP) • Collaborative – shared decision making • Avoid fixation on med compliance • Decatastrophizing (Diagnosis is not Destiny) • Use of texting/Social media/Apps
TAY Stage Specific Supports Tunin’ Up
Rollin’ In
Rockin’ Out
“FLOW“ Engaging Retaining Connecting Graduating
Welcome, engage, and outreach
1 Extreme Risk
2 High Risk /Not Engaged
3 High Risk/ Engaged
Milestones of Recovery Scale 4 5 6 Poorly Coping/ Not Engaged
Poorly Coping/ Engaged
Coping/ Rehabilitating
7 Early Recovery
8 Advanced Recovery
Hart’s Ladder: Degrees of Youth Participation
Continuum of Helping Relationships Psychotherapy
Peers as Providers of Conventional Services
One Directional Case Management
Youth Driven Programming
Reciprocal Peer Support
Friendship
Youth Mentors/Peer Supporters • Youth-friendly environments & relationships • Change organizational culture • Welcoming • Taking time • Embodiments of hope • Side-by-side learning • Navigational support • Advocacy • TAY Sherpa’s
S.N.A.P. Assessment •Strengths •Needs •Abilities •Preferences SAMHSA NITT-TA Toolkit Chapter 1
Social Media/Texting/Apps • Facebook • Mental Health Instagram • Crisis texting • “Compassionate” texting • Youth oriented Smart-phone apps
Engaging Hearts through Arts
Be serious about having FUN!!!
Providing Trauma Informed Care to Youth & Young Adults
Trauma Informed Care: Why so Important? • Trauma is pervasive among TAY population • Trauma is under-reported • Trauma is under-recognized • Trauma is under-treated
• A mis-labeled person is a mis-treated person
ACES Research “Because the transition to adulthood is a watershed developmental period, the mental health consequences of ACEs are likely to have far-reaching impact by disrupting the establishment of positive roles and relationships that set the course for adult occupational and social attainment” – E.Shilling 2007
The Whack-a-Mole Approach? Depression
Homelessness
Psychosis
Anxiety
Substance Abuse
Borderline PD
The Trauma Informed Paradigm Shift
From: What’s wrong with you? To: What happened to you?
Integrate TIC into Substance Abuse Treatment • Significant nexus between trauma & SUD – expectation not exception • Self medicating/adaptation • Teach emotional regulation • Harm reduction • Resilience development
Instilling Hope & Future Vision • Continuous Strength Discovery and Future Planning • Encourage the young survivor to aspire to a more positive future and regain a sense of hope - Najavits (2009) • Discuss post-traumatic growth – explore how trauma can also contribute to resilience, ex: stronger, wiser, more aware and empathetic - Tedeschi & Calhoun (2004) • Countering sense of shame, “badness”, damaged goods
Starting Conversations about Trauma Normal reactions to Abnormal events and experiences
Discovering Trauma Related Strengths & Adaptations (Reframing) Symptoms/Dysfunctions Drug & alcohol abuse Distrustful/suspicious Impulsive Manipulative/splitting Dissociation Passive/dependent Assaultive Cutting/self-mutilating
Adaptive/Coping/Need Self-medicating Self-protective Quick acting Managing people & emotions Avoiding bad memories Staying safe – avoiding risks Stands up for self Distracting/ self-regulating
Options for Coaching Self-Management • For YP – (Modeling ) Watch me do this 3 minute Breathing App and see how easy it is to use. (Show how relaxed & refreshed you are afterwards.) Do you want to give it a try?
• With YP – Let’s try this out together! What did you think? (side-by-side) Do you notice feeling any less stressed? Is your Stress-O-Meter any lower now? (scaling) Want to try it out this weekend?
• By YP – Try this out over the weekend, whenever you get stressed, text me how it goes, or tell me about it when I see you early next week (practice)
Tapping APPS? Emotional Coaching in (their) pocket?
Compassionate Self-Talk • Ask YP to notice harsh, critical self-talk – (e.g. I’ll never make it, I’m so stupid, I’m unlovable, I don’t deserve anything) • Ask them to try out some positive, supportive statements – what would they say to their best friend? (Important that YP says it) •
Developing Resiliency ~ How can we do it?
Serious Career Development for Youth with Serious Mental Health Conditions
Katie’s Story (con’t)
What if Career Development was the overarching purpose of TAY programs? • Doorway into disability & poverty or improved access to meaningful roles? • • • • •
TAY Career Development Whatever the level of impairment (limited predictability) Center Soft bigotry of low expectations The dignity of risk and right to failure What would TAY program staffing look like? What impact does Federal disability have on emerging adults?
• Symptom reduction does not equal recovery
Comparing Individualized Placement & Support & HYPE Principles
Additional Principles Unique to HYPE Cultivation of Identity of Worker & Student Informed Decision Making Involvement in Developmentally-Relevant Integrated Settings Systematic Resource Development Focus on Community Support
Active ongoing benefits counseling • What is impact of Federal disability (SSI & SSDI) on emerging adults?
• Safety Net or Snare? (Less than 1% of SSI recipients ever go off benefits) • Cultivating a non-disabled identity • Work Incentives (Ticket to Work) • Benefits calculator
“We’re weakest where we should be strongest”
Patrick McGorry M.D.
School & Work: Promoting Protective Factors/Resiliency
TOP 5 Things They Never Teach you in Employment Training 1. Using your “sick voice” when calling in sick (and keep your stereo down) 2. Learning how to act busy 3. Exerting facial control when boss is giving you directions (avoid eye rolling) 4. Always have next job lined up before you tell boss what you think of him/her 5. Recognize that being asked “How are you?” – is not a clinical assessment
Matching Strategy to Stage of Change • Career Stage of Change?
• Career Development Strategy?
• Career Pre-Contemplators
• Maintain Engagement
• Career Contemplator
• Routine “Exposures”
• Career Preparer • Career Initiator • Career Maintainer
• Internships/Job Shadows • Place & Train • Job Club
Helping to create a future vision: My Future Story
Routine school & job exposures • • • • • • • • • •
From Recovery to Discovery Ground-Hog Day Job Shadows Paid & Non-paid internships Peer Advocates/Peer Supporters School/Campus Tours Job Tours School/job panels Volunteer Audit classes Follow the Fun
Toolkits to Support Full Inclusion of Students w/ Early Psychosis in Higher Education – Felton Inst.
A Few More Ideas… • Capitalizing on our own (TAY & MH programs) resources and opportunities • Partnerships (esp Community Colleges) • Agency owned businesses • Peer Training & Career Track
Psychosis Sucks! Working with Young People in Severe Distress
No One Size Fits All ~ Incredible Heterogeneity
Establish Early Intervention Psychosis • Support choice in understanding • Tremendous heterogeneity • Traumagenic very common • Hopelessness/Helplessness • Life-long brain disease – not engaging or evidence based Broaden/inclusive engagement pathways
Understanding Psychosis & Schizophrenia
“Prof’s should not insist that people accept any one particular framework of understanding, for example that their experiences are sx’s of mental illness.”
What is your “explanatory” model? (Psychosis is caused by_____)? • Chemical Imbalance/Brain Disease – Disorder? • Cultural? • Genetic? • Stress/vulnerability? • Spiritual crisis? • Trauma induced? • A desperate survival strategy – an adaptation?
HOPELESSNESS/HELPLESSNESS METER
Recovery? No Way!
Recovery? Maybe?
Recovery-YES WAY!
What’s in your Psychosis Toolkit?
Embrace Curiosity •Ask questions •Don’t make assumptions •Be open to different explanations •Explore all possibilities
Dialogue Starters
Normalize • Main factor in predicting good clinical outcomes
•How do we do it?
Reducing Distress •Identifying triggers •Scaling distress
•Teaching emotional regulation •Mindfulness
Exercise! “Miracle-Gro for the Brain”
How can we increase physical activity into our work with young people?
Med Collaboration Use Whatsup? (TIP tool based on MI) What concerns does youth have about taking meds? How do concerns effect/fit in with youth’s Future Plans/goals? Ask about options – are there add’l ways, alternatives to meds that youth has considered that might help? Talk about what works about meds/what doesn’t – LISTEN! See Stage of Change? Understand ambivalence Plan for next steps, continued conversation, coach for MD talk
Hearing Voices Networks
Coping with Voices Ron Unger • Using earplugs • Repeating everything • Rating the voices • Physical exercise • Reality Testing • Give the voices an accent • Using Art
• Questioning the voices • Reframing the voices • Distracting • Negotiating TIME OUT • Getting to know emotions behind the voices • Programming you I-Pod
IMPORTANT Work!
Let’s keep the world of possibilities and Future Plans open for youth
TAY What? Wrap-Up & Questions
Katie Holloway Research Assistant Student [email protected]
Institute Objectives • Assess & apply cross-cutting service delivery principles to transition services
• Identify and evaluate key components of effective transition services, including engagement, trauma informed care, career development and early intervention psychosis • Share transition resources, tools and strategies
Dr. Evil’s TAY Program
2 Big Picture Questions How does current Medical Model impact young people? (Distress vs Disease)
How do we better support and promote healthy “Interdependence” ?
5 Key Elements of TAY Systems of Care Engagement Strategies/Retention Trauma Informed
Supported Ed + Emp
Integrated Sub Abuse
Is it safe?
Is it relevant?
Is it accepting?
Early Intervention Psychosis
Is it flexible?
90%
How we doing?
16
80%
14
70%
12
60%
10
50%
8
40%
6
30% 20%
4
10%
2
0%
0 Complete HS
Currently Employed
Post-secondary Recent Enrollment police/arrest/jail
TAY w/SMHC
General TAY Population
Duration of Employment (months)
The Good News “You suck less”
4 Principles of Transitional Services • Are you connected to your community? • Are you developmentally informed?
• Are you culturally attuned? • Are you oriented to Stages of Change?
Establish Community Partnerships – No one program can do it all
•No Wrong Door •Bridging •Peer Navigation Support •Warm Hand offs •Meet Survival Needs
Developmentally Informed? Meeting the challenge of recognizing & responding to developmental stage: • When we expect too little – children oriented (tendency to over protect, over help, avoid risk, condescend
Ave. Age of Emancipation = 32 y/o! • When we expect too much - adult oriented (tendency to assume youth have developed self-responsibility, goal directed skills, prematurely discharge
Culturally Attuned •Youth Culture
•Respectful Curiosity •“Independence”
Stage of Change Oriented? Matching Interventions to Stage of Change (Employment, Education, Therapy, Substance Use)
Engaging (while not Enraging) Youth & Young Adults
Katie’s Story
Engagement • Relationship = Resiliency • Strength-Discovery and Future Plans (TIP) • Collaborative – shared decision making • Avoid fixation on med compliance • Decatastrophizing (Diagnosis is not Destiny) • Use of texting/Social media/Apps
TAY Stage Specific Supports Tunin’ Up
Rollin’ In
Rockin’ Out
“FLOW“ Engaging Retaining Connecting Graduating
Welcome, engage, and outreach
1 Extreme Risk
2 High Risk /Not Engaged
3 High Risk/ Engaged
Milestones of Recovery Scale 4 5 6 Poorly Coping/ Not Engaged
Poorly Coping/ Engaged
Coping/ Rehabilitating
7 Early Recovery
8 Advanced Recovery
Hart’s Ladder: Degrees of Youth Participation
Continuum of Helping Relationships Psychotherapy
Peers as Providers of Conventional Services
One Directional Case Management
Youth Driven Programming
Reciprocal Peer Support
Friendship
Youth Mentors/Peer Supporters • Youth-friendly environments & relationships • Change organizational culture • Welcoming • Taking time • Embodiments of hope • Side-by-side learning • Navigational support • Advocacy • TAY Sherpa’s
S.N.A.P. Assessment •Strengths •Needs •Abilities •Preferences SAMHSA NITT-TA Toolkit Chapter 1
Social Media/Texting/Apps • Facebook • Mental Health Instagram • Crisis texting • “Compassionate” texting • Youth oriented Smart-phone apps
Engaging Hearts through Arts
Be serious about having FUN!!!
Providing Trauma Informed Care to Youth & Young Adults
Trauma Informed Care: Why so Important? • Trauma is pervasive among TAY population • Trauma is under-reported • Trauma is under-recognized • Trauma is under-treated
• A mis-labeled person is a mis-treated person
ACES Research “Because the transition to adulthood is a watershed developmental period, the mental health consequences of ACEs are likely to have far-reaching impact by disrupting the establishment of positive roles and relationships that set the course for adult occupational and social attainment” – E.Shilling 2007
The Whack-a-Mole Approach? Depression
Homelessness
Psychosis
Anxiety
Substance Abuse
Borderline PD
The Trauma Informed Paradigm Shift
From: What’s wrong with you? To: What happened to you?
Integrate TIC into Substance Abuse Treatment • Significant nexus between trauma & SUD – expectation not exception • Self medicating/adaptation • Teach emotional regulation • Harm reduction • Resilience development
Instilling Hope & Future Vision • Continuous Strength Discovery and Future Planning • Encourage the young survivor to aspire to a more positive future and regain a sense of hope - Najavits (2009) • Discuss post-traumatic growth – explore how trauma can also contribute to resilience, ex: stronger, wiser, more aware and empathetic - Tedeschi & Calhoun (2004) • Countering sense of shame, “badness”, damaged goods
Starting Conversations about Trauma Normal reactions to Abnormal events and experiences
Discovering Trauma Related Strengths & Adaptations (Reframing) Symptoms/Dysfunctions Drug & alcohol abuse Distrustful/suspicious Impulsive Manipulative/splitting Dissociation Passive/dependent Assaultive Cutting/self-mutilating
Adaptive/Coping/Need Self-medicating Self-protective Quick acting Managing people & emotions Avoiding bad memories Staying safe – avoiding risks Stands up for self Distracting/ self-regulating
Options for Coaching Self-Management • For YP – (Modeling ) Watch me do this 3 minute Breathing App and see how easy it is to use. (Show how relaxed & refreshed you are afterwards.) Do you want to give it a try?
• With YP – Let’s try this out together! What did you think? (side-by-side) Do you notice feeling any less stressed? Is your Stress-O-Meter any lower now? (scaling) Want to try it out this weekend?
• By YP – Try this out over the weekend, whenever you get stressed, text me how it goes, or tell me about it when I see you early next week (practice)
Tapping APPS? Emotional Coaching in (their) pocket?
Compassionate Self-Talk • Ask YP to notice harsh, critical self-talk – (e.g. I’ll never make it, I’m so stupid, I’m unlovable, I don’t deserve anything) • Ask them to try out some positive, supportive statements – what would they say to their best friend? (Important that YP says it) •
Developing Resiliency ~ How can we do it?
Serious Career Development for Youth with Serious Mental Health Conditions
Katie’s Story (con’t)
What if Career Development was the overarching purpose of TAY programs? • Doorway into disability & poverty or improved access to meaningful roles? • • • • •
TAY Career Development Whatever the level of impairment (limited predictability) Center Soft bigotry of low expectations The dignity of risk and right to failure What would TAY program staffing look like? What impact does Federal disability have on emerging adults?
• Symptom reduction does not equal recovery
Comparing Individualized Placement & Support & HYPE Principles
Additional Principles Unique to HYPE Cultivation of Identity of Worker & Student Informed Decision Making Involvement in Developmentally-Relevant Integrated Settings Systematic Resource Development Focus on Community Support
Active ongoing benefits counseling • What is impact of Federal disability (SSI & SSDI) on emerging adults?
• Safety Net or Snare? (Less than 1% of SSI recipients ever go off benefits) • Cultivating a non-disabled identity • Work Incentives (Ticket to Work) • Benefits calculator
“We’re weakest where we should be strongest”
Patrick McGorry M.D.
School & Work: Promoting Protective Factors/Resiliency
TOP 5 Things They Never Teach you in Employment Training 1. Using your “sick voice” when calling in sick (and keep your stereo down) 2. Learning how to act busy 3. Exerting facial control when boss is giving you directions (avoid eye rolling) 4. Always have next job lined up before you tell boss what you think of him/her 5. Recognize that being asked “How are you?” – is not a clinical assessment
Matching Strategy to Stage of Change • Career Stage of Change?
• Career Development Strategy?
• Career Pre-Contemplators
• Maintain Engagement
• Career Contemplator
• Routine “Exposures”
• Career Preparer • Career Initiator • Career Maintainer
• Internships/Job Shadows • Place & Train • Job Club
Helping to create a future vision: My Future Story
Routine school & job exposures • • • • • • • • • •
From Recovery to Discovery Ground-Hog Day Job Shadows Paid & Non-paid internships Peer Advocates/Peer Supporters School/Campus Tours Job Tours School/job panels Volunteer Audit classes Follow the Fun
Toolkits to Support Full Inclusion of Students w/ Early Psychosis in Higher Education – Felton Inst.
A Few More Ideas… • Capitalizing on our own (TAY & MH programs) resources and opportunities • Partnerships (esp Community Colleges) • Agency owned businesses • Peer Training & Career Track
Psychosis Sucks! Working with Young People in Severe Distress
No One Size Fits All ~ Incredible Heterogeneity
Establish Early Intervention Psychosis • Support choice in understanding • Tremendous heterogeneity • Traumagenic very common • Hopelessness/Helplessness • Life-long brain disease – not engaging or evidence based Broaden/inclusive engagement pathways
Understanding Psychosis & Schizophrenia
“Prof’s should not insist that people accept any one particular framework of understanding, for example that their experiences are sx’s of mental illness.”
What is your “explanatory” model? (Psychosis is caused by_____)? • Chemical Imbalance/Brain Disease – Disorder? • Cultural? • Genetic? • Stress/vulnerability? • Spiritual crisis? • Trauma induced? • A desperate survival strategy – an adaptation?
HOPELESSNESS/HELPLESSNESS METER
Recovery? No Way!
Recovery? Maybe?
Recovery-YES WAY!
What’s in your Psychosis Toolkit?
Embrace Curiosity •Ask questions •Don’t make assumptions •Be open to different explanations •Explore all possibilities
Dialogue Starters
Normalize • Main factor in predicting good clinical outcomes
•How do we do it?
Reducing Distress •Identifying triggers •Scaling distress
•Teaching emotional regulation •Mindfulness
Exercise! “Miracle-Gro for the Brain”
How can we increase physical activity into our work with young people?
Med Collaboration Use Whatsup? (TIP tool based on MI) What concerns does youth have about taking meds? How do concerns effect/fit in with youth’s Future Plans/goals? Ask about options – are there add’l ways, alternatives to meds that youth has considered that might help? Talk about what works about meds/what doesn’t – LISTEN! See Stage of Change? Understand ambivalence Plan for next steps, continued conversation, coach for MD talk
Hearing Voices Networks
Coping with Voices Ron Unger • Using earplugs • Repeating everything • Rating the voices • Physical exercise • Reality Testing • Give the voices an accent • Using Art
• Questioning the voices • Reframing the voices • Distracting • Negotiating TIME OUT • Getting to know emotions behind the voices • Programming you I-Pod
IMPORTANT Work!
Let’s keep the world of possibilities and Future Plans open for youth
TAY What? Wrap-Up & Questions
